Mary Putnam Jacobi, M. D., a pathfinder in medicine, with selections from her writings and a complete bibliography;

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MARY PUTNAM JACOBI, M.D.

A PATHFINDER IN MEDICINE

WITH SELECTIONS FROM HER WRITINGS

AND

A COMPLETE BIBLIOGRAPHY

EDITED BY
THE WOMEN'S MEDICAL ASSOCIATION

OF

NEW YORK CITY

G.P.Putnam's Sons
^^ewYork ^ London

XThc IR-nickerbockeriPrega
1925

nn

3"3

Copyright^ i9£Sr
by
The Women's Medical Association of New York City, Inc.

^%,

Made in the United States of America

To
ELIZABETH BLACKWELL, M.D.

"Among all the pioneer group of women physicians, hers
chiefly deserves to be called the Record of an Heroic Life."

Women in Medicine — Mary Putnam Jacobi, M.D.

(14101

FOREWORD

The Women's Medical Association of New York City, desires
to perpetuate the memory of the work done by one of its founders,
one of the great pioneer women in medicine. She opened the
doors of a great university that women might equally with men
obtain a scientific medical education. All her life she was a
zealous worker for this advancement of the medical education
of women. To continue this, her work, the Association has
founded the Mary Putnam Jacobi Memorial Fellowship, thus
far awarded four times, to increase the medical knowledge of the
recipients. The Association in this volume has collected some
of her medical writings, illustrating her studies on the medical
problems of her day. With her writings as with her other medi-
cal work, "she was never satisfied. There was always a better
than her best, a higher than her highest to be striven for; and
ii this striving she was not influenced by personal ambition, but
by the higher object — the truth to be attained."

CONTENTS

PAGE

Foreword ........ xi

Physician, Teacher, Author ..... xiii

Member of Medical Societies .... xxviii

Mary Putnam Jacobi ...... xxxi

Letters to the Medical Record, 1867- 1870 — Medical

Matters in Paris. Signed P. CM. . . . i

Some Details in the Pathogeny of Pyemia and Sep-
ticemia ........ 171

Report of an Address to the Graduating Class of
THE Woman's Medical College of the New York
Infirmary ........ 201

On Atropine ........ 204

Pathogeny of Infantile Paralysis .... 240

Remarks upon the Action of Nitrate of Silver on

Epithelial and Gland Cells .... 284

Sphygmographic Experiments upon a Human Brain,

Exposed by an Opening in the Cranium . . 299

Acute Fatty Degeneration of the New-Born . 311

viii Contents

PAGE

Contribution to Sphygmography . . . .326

Case of Facial and Palatine Paralysis, and Loss of

Equilibrium, Produced by a Fall on the Head 329

Inaugural Address at the Opening of the Woman's
Medical College of the New York Infirmary,
October i, 1880 .... . . 334

Specialism in Medicine 357

Shall Women Practice Medicine? .... 367

An Address Delivered at the Commencement of the
Woman's Medical College, of the N. Y. Infirm-
ary, May 30, 1883 391

Opening Lecture on Diseases of Children, at the

Post- Graduate Medical School, New York . 403

The Indication for Quinine in Pneumonia
Case of Probable Tumor of the Pons
The Practical Study of Biology

Hysterical Fever

Modern Female Invalidism

419
446

458
463
478

A Suggestion in Regard to Suggestive Therapeutics 483

Address Before the Women's Medical Association

About 1900 494

Contents ix

PAGE

Description of the Early Symptoms of the Meningeal
Tumor Compressing the Cerebellum, from WHipfi •
THE Author Died. Written by Herself . . 501

Bibliography 505

Index 513

MARY PUTNAM JACOBI
A Pathfinder in Medicine

MARY PUTNAM JACOBI

PHYSICIAN, TEACHER, AUTHOR

A diploma from the Female Medical College of Pennsylvania,
in 1864, marked the entrance into the medical profession of Mary
C. Putnam.' A year as interne in the New England Hospital
followed.^ The desire for a medical education absolutely un-
attainable in the United States, led her, as it has always led
pioneers, "through tangled underwood of old traditions, out to
broader ways," even to the doors of the Paris I'ficole de M^decine,
to which women had not been admitted. The romantic story
of this adventure, beginning in 1866, she relates in her letters
from Paris to her beloved mother.^ She was the first woman
to be admitted to the French school. Her thesis, written during
the Siege of Paris in the Franco-Prussian War, received the
bronze medal.''

' The Female Medical College of Pennsylvania was founded in 1850,
"and after a long and precarious period of struggle, finally touched upon a
solid basis of medical realities and thence began its prosperous modern career. "

The title of the college was, in 1867, changed by decree of court to that
of the Woman's Medical College of Pennsylvania. It is now (1924) the only
medical college in the United States devoted exclusively to the education of
women in medicine.

' The New England Hospital, founded in 1862, the second hospital in the
United States conducted by women ph^^sicians.

3 Volume I, Letters.

* The copy of the thesis in the New York Academy of Medicine, was
presented to the New York Hospital Library, April 23, 1892, by Francis D.
Buck, M.D., and passed to the Academy of Medicine with the library of the
Society of the New York Hospital, March, 1898.

xiv Mary Putnam Jacobi

Returning to New York in September, 1871, with what Sir
William Osier described as "a Paris medical degree and a training
in scientific medicine unusual at that date even among men,"
she immediately opened an office in her father's house, 328 East
15th Street, and began private practice. She entered at once
into the professional life of the city, and joined in the discussions
of those medical societies to which women were admitted.' The
first such discussion seems to have been at a meeting of the
Medical Library and Journal Association.^ It was before this

News items, Med. Record, 1871 (September 15), page 335:

Mary Putnam

"Miss Putnam," says a Paris paper, "the young American who has for
some 5'ears been following the course in Tficole de M6decine, submitted her
graduating thesis to the Faculty. It was read in the large lecture room of
the College before a numerous audience, and was received with warm com-
mendation. The President of the Board of Examiners found it deserving of
the highest note — 'extr^mement satisfait.' This mark is rarely given for a
thesis. Miss Putnam has also received the highest mark at each of her five
examinations. She was ready for graduation a year ago, but the war broke
up the schools, and she has devoted the year to work in the hospitals. She is
the first woman who obtained admission to I'ficole de M^decine, but not the
first who graduated, as Miss Garret took a year's course and received her
degree a year or more ago. She writes that one of the dedications of her
thesis was as follows: 'To the professor, whose name I do not know, who
alone voted in favor of my admission to the £cole, thus protesting against the
prejudice that would exclude women from superior studies.' One of the
professors on the board took up the dedication, read it aloud to the audience,
and then defended himself from the accusations. He 'had never voted,
he had no such prejudice, he did not believe that it existed in the faculty, etc.,
and he considered the claim for right to participate in the superior studies a
most legitimate demand. '

" Miss Putnam writes: 'I confess I should not be sorry to have that part
of the stance stereotyped for the benefit of New York schools of medicine."

' First medical discussion found. Med. Record, vol. vi, page 448. Meet-
ing of the Medical Library and Journal Association, October 27, 1871. The
topic under discussion: The gj^mnastic treatment of chorea.

"Doctor Mary C. Putnam, who had closely followed the clinic of the
Hdpital des Enfants (rue de Sevres) for the last four years, replied to a ques-
tion by Doctor Seguin that the gymnastic treatment was still regularly em-
ployed there for all choreics able to be out of bed. The milder cases received
also sulphuret of potassium baths! Those more severe arsenic! And the
worst tartar emetic."

' The Medical Library and Journal Association of New York, organized
in 1864, to establish a medical reading room and to make the library a nucleus

Physician, Teacher, Author xv

Association that the young doctor read the first paper presented
to a medical society , in the United States, by a medical woman. ^

Physician. 1871-1902

"Honour a physician with the honour due unto him for the uses which ye
may have of him: for the Lord hath created him. The Lord hath created
medicines out of the Earth and he that is wise will not abhor them." (Ec-
clesiasticus, Chapter 38.)

The work of a large private practice, attendance at the
dispensary and teaching in the college and in the hospital, made
what she herself called a "busy day." A private patient said
of her "that she was a physician dedicated to the work of helping
her fellow-mortals." She was always ready at the moment of
greatest necessity.

When the doctor returned from Paris, there were but four
hospitals in the United States where a woman was eligible as an
attending physician.^ One dispensary, that of the New York
Infirmary, offered her a position on its staff. ^ The Infirmary
treated in its little hospital, the first year after the doctor's
return from Paris, 144 patients, and this after circulars had been
sent in the early part of the season to all clergymen and heads
of benevolent societies, stating the nature of the cases received. '^
[These patients and those in private practice were studied withH
the enthusiasm which was a marked characteristic of Dr. Mary
Putnam Jacobi. One of the first patients presented an unusual
deformity of the heart and this was shown at the New York Path-

for a club room. "Stated reunions " were held every Friday evening. "First
class papers are read followed by profitable discussions. The Constitutions
for 1864 defines those physicians eligible for membership as "any regular and
reputable medical man." The Constitution for 1865 omits the word "man"
and the doctors Elizabeth and Emily Blackwell were admitted to membership.
The Association was merged into the Academy of Medicine.

' "Women in Medicine" in Woman's Work in America, Mary Putnam
Jacobi, M.D.

* The New York Infirmary, 1857.
The Woman's Hospital, Philadelphia, 1862.
The New England Hospital, 1863.
The Woman's Hospital, Chicago, 1865.

3 The students of the college were admitted to certain dispensaries, but
only the undergraduates.

•< Infirmary Report, Jan. i, 1872.

xvi Mary Putnam Jacobi

ological Society, at a meeting, February 14, 1872.' cThe study
of pharmacology occupied much of her time^' A lecture on one
of these early studies was delivered to the students of the col-
lege. ^ Lectures on " Medical Botany " were given at the college. ^
In 1873, Dr. Mary Putnam Jacobi and Dr. Anne A. Angel,
a graduate of the Women's Medical College of the New York
Infirmary, in 1871, obtained permission from the managers of
the Mount Sinai Hospital to attend the children brought to the
dispensary. This included all the children under twelve years
of age, who applied to the dispensary for medical, surgical or
orthopedic aid. Dr. Jacobi continued to attend until 1886.
\^Thus she was responsible for the founding of the pediatric dis-
pensary service at Mount Sinai Hospital, and from 1873 to the
present time, a woman physician has been continuously in charge
of this clinic. Prom 1871 to 1897, Dr. Jacobi served the In-
firmary as visiting, attending and as consulting physician.
From the opening of the hospital, in 1853, until 1886, sick chil-
dren had been placed in the wards with adults, there being no
other place for them. In 1886, Dr. Jacobi opened a little ward
containing three beds. The Infirmary report for 1886 notes
the fact "that one object for which the Infirmary had been in-
corporated had been carried out in this year by the opening of
a children's ward, completing the name. The Infirmary for
Women and Children." In 1891, as a result of her work the
ward_contained fourteen beds_.^^

From 1893 to 1902, Dr. Jacobi was a visiting physician to St.
Marks Hospital. ^

' Anomalous malformation of the heart, Med. Record, 1872, vii.

^ Lecture on atropin, Med. Record, 1873, viii.

i Report Woman's Medical College of the New York Infirmary, 1872.
Mary C. Putnam, M.D., Lectures on Medical Botany.

•< The New York Infirmary for Women and Children, "Chartered in 1854
as a dispensary, opened with an indoor department, in 1857. From 1857
until 1865, the indoor department of the infirmary was limited to a single
ward for poor lying-in women which contained but twelve beds, but in the
dispensary several thousand patients a year were treated, and the young
physicians living in the hospital also visited the sick poor in their homes.
In 1S65, a new building was purchased for the hospital, which became enlarged
to the capacity of thirty-five beds." Women in Medicine in America, by
Mary Putnam Jacobi, M.D.

5 Incorporated, 1890.

Physician, Teacher, Author xvii

Teacher

Woman's Medical College of the New York Infirmary,
1871-1889.

Lectures on materia medica and medical botany, 1871-1872.

Professor of Materia Medica, 1 872-1 873.

Professor of Materia Medica and Therapeutics, 1873- 1889.

New York Post-Graduate Medical School, Clinical Lectures
on Diseases of Children, 1 882-1 885.

"There is no power on earth which setteth up a throne or chair of state in
the spirits and souls of men and in their cogitations, imaginations, opinions
and beliefs, but knowledge and learning." — Bacon.

"After the Blackwells, the most important factor in the
movement that brought about the introduction of medical educa-
tion for women and probably to be considered after them only in
time, for her professional influence was co-ordinate with theirs,
was Mary Putnam Jacobi^"] ^ "It was at the time of the greatest
difficulty and disco-uragement for women students and practi-
tioners" when Mary C. Putnam returned from Paris, in 1871.
The standards for entering the medical profession were easy of
attainment; women "without means or preliminary education
could obtain a degree with almost nominal education. It seemed
as though the low standard of qualifications then established
would prove the most formidable barrier to the success of women
in the profession," Mary C. Putnam "brought as her contribu-
tion to the new work an enthusiastic love of the scientific side of
medicine and a high standard of medical education."^

While still a student in Paris the faculty of the little college^
established by the Doctors Elizabeth and Emily Blackwell had

' Walsh. History of Medicine in New York State, vol. i, p. 317.

' Dr. Emily Blackwell, Mary Putnam Jacobi Memorial Meeting Address.

3 "In New York, after much hesitation, a charter was obtained in 1865
for the establishment of a medical college in connection with the Infirmary.
This step was taken reluctantly because the desire of the Trustees of the
Infirmary was not to found another medical school, but to secure the admis-
sion of women to the classes for instruction already organized in connection
with the medical charities of the city, and to one at least of the New York
medical colleges. The demand of women for a medic^ education had resulted
in the founding of small colleges in different places, all, with the exception of
the Philadelphia school, limited to the narrow and cheap standard of legal
requirements, and producing equally cheap and narrow results in the petty
standard of medical education they were establishing among medical women

xviii Mary Putnam Jacobi

been waiting for the aid that the accomplished young doctor was
to give them. Dr. Putnam had been asked by the Doctors
Blackwell to join the faculty and teach materia medica in the
new college. At the faculty meeting, May 6, 1870, the Secre-
tary reported "that the return of Dr. Mary Putnam would
be delayed by the closing of the University of Paris." The
Franco-Prussian War had interrupted her studies. In October,
187 1, Dr. Putnam began the lectures on materia medica and
in the Spring Session on Medical botany. At the faculty meet-
ing, April 26, 1872, "It was resolved that the faculty recommend

students. The establishment of such a school called for money, but the money
was forthcoming. A prospectus was issued announcing the requirements.
In this prospectus a bold attempt was made to outline a scheme of education
which should not only satisfy the conventional existing standard but improve
upon this. It was realized, and, oddly enough, for the first time, that the
best way to compensate the enormous disadvantages under which women
physicians must enter upon their work was to prepare them for it with peculiar
thoroughness. Women students were almost universally deficient in pre-
liminary intellectual training; their lesser physical strength rendered a cram-
ming system more often dangerous to health, and more ineffective as a means
of preparation; and the prejudices to be encountered in their medical career
would subject them not only to just but also to abundant unfair criticism.
Instead therefore, of the senseless official system which then everywhere
prevailed, it was proposed to establish a three years' graded course, with
detailed laboratory work during the first years, and detailed clinical work
during the last. A chair of hygiene was established for the first time in
America, and an independent Board of Examiners was appointed consisting
of professors from the diflferent city schools. By this means, the college
voluntarily submitted itself to the external criticism of the highest local
authorities. When the Infirmary put forth this prospectus, drawn up by
the Doctors Blackwell, no college in the country required such a course. It
was deemed Quixotic by many medical friends and several of its features were
for a time postponed. The independent board of examiners, however, was
established from the beginning, and, little by little, the other parts of the
scheme were realized. In 1876, the three year's graded course, at first optional
was made obligatory. At this time no college but Harvard had taken this
step. The next year the class fell off one-third — a curious commentary on
the character or circumstances of the students. In 1881, the college year was
lengthened to eight months, thus abandoning the time-honored division of a
winter and spring course, the latter comparable to the Catholic works of su-
pererogation, and equally neglected. At the same time entrance examinations
were established. These moderate improvements upon the naive barbarism
of existing customs again reduced the classes one-half. When people first
began to think of educating women in medicine, a general dread seemed to
exist that, if any tests of capacity were applied, all women would be excluded.

Physician, Teacher, Author xix

to the Board of Trustees to invite Dr. Putnam to continue for
another year as lecturer on materia medica with the honorary
title of Professor." '

At the faculty meeting, September 27, 1872, Mary C. Putnam,
M.D., is recorded as present. From that date until her resigna-
tion in 1889, her active interest in the college and its students
never flagged. It was her constant aim to make the work of her
department more comprehensive, more thorough and more
useful. She divided her subject into materia medica and thera-
peutics. The former was taught during the first year and the
latter during the two following years. The reasons for the
change are eloquently and forcibly set forth in the introductory
paragraph of the Lecture on Atropin. The college catalogue
for 1873, notes the change.

The interest of the young professor of materia medica and
therapeutics was not limited to the problems of her own depart-
ment. The question which concerned her, and which she studied
from every point of view,[was the education of women as prac-
titioners of medicine.'

The profound skepticism felt about women's abilities was thus as much mani-
fest in the action of the friends to their education as in that of its opponents.
But by 1882, the friends dared to "call upon those who believe in the higher
education of women, to help to set the highest possible standard for their
medical education, and upon those who do not believe in such higher educa-
tion to help in making such requirements as shall turn aside the incompetent —
not by an exercise of arbitrary power, but by a demonstration of incapacity,
which is the only logical manly reason for refusing to allow women to pursue
an honorable calling in an honorable way. A career is open to women in the
medical profession, a career in which they may earn a livelihood; a career in
which they may do missionary work among the poor of our own country, and
among their own sex in foreign lands; a career that is practical, that is useful,
that is scientific. Even when a theoretic demand is not entirely realized in
the actual facts of the case, its distinct enunciation remains a great achieve-
ment; and, in an almost mysterious way, constantly tends to effect its own
ultimate realization, and so it has been here." "Women in Medicine" by
Mary Putnam Jacobi, M.D., in Woman's Work in America.

The college closed in 1899. The opening of a medical department of
Cornell University, admitting women, rendered a separate college for women
unnecessary.

■ Faculty minutes of the Woman's Medical College of the New York
Infirmary, May 6, 1870; April 26, 1872.

- Faculty minutes, March 7, 1873.

XX Mary Putnam Jacobi

In 1880, the faculty reported favorably upon the request of
Dr. Jacobi to hold a weekly quiz for the entering students in
anatomy and physiology. This weekly quiz became later "A
Physiological Introduction to Therapeutics," given to the first
year students Friday afternoons. Thirty-five years later, one
of the students remembers vividly this quiz in the old college.
"Its scope was not limited to anatomy, to physiology' nor to
therapeutics, but embraced all related subjects as they were sug-
gested by the question under discussion. Thus, the study of any
organ meant a very comprehensive knowledge of its gross and
microscopic structure, the source of its nerve and blood supply,
its physiology, its correlation with its neighbors in the body.
The study of any drug meant the accurate knowledge of its
source and preparation and the botanical classification of the
plant from which it was derived. Incidental questions of
geography, history and literature were also discussed, and
ranged through the subjects of medicine, ancient and modern
history and the literature of the world. It was the most stimu-
lating course in the first year, full of phenomenal new vistas to a
young medical student."

" At the first meeting of this class. Dr. Putnam Jacobi in-
variably called the roll, looked at each student with a friendly
open-hearted glance and asked, 'Where did you obtain your
preliminary education?' The doctor knew each student by
name after that first session, and on later occasions a stupid

answer often brought out the retort, 'As a graduate of

School, you should know better.' But no matter how stupid
nor how uninformed she found her students, she was always
patient, friendly and above all, stimulating. The sessions were
rarely completed in less than two hours, and by that time there
was always a long list of medical questions to be looked into.
Incidentally, there were non-medical articles to be read. Never
a Friday afternoon that did not stimulate much more than
materia medica proper, never a Friday that was dry or dull.
The will to learn was what she demanded of her students. She
credited them with the mental ability and the industry to do the
tasks required. She demanded much, but she gave in over-
flowing measure, and never spared herself."'

■ Martha Wollstein,

Physician, Teacher, Author xxi

V

"To her students, Dr. Putnam taught the value of well directed effort

for itself alone. No amount of time was too great, no labor too arduous to
devote to their interest. She exacted in return care and thought and scientific
accuracy. She would not tolerate superficial methods, while for honest intel-
ligent effort, her appreciation was unbounded, and her encouragement, and
help always ready. She stimulated others to do the best in their .power, and
made them realize through her own ideals the greatness of the work which
was before them." '

The entire problem of women in medicine, especially as
practitioners of medicine was still debated. Dr. Jacobi realized
fully that every student at the college, as a potential woman
physician, must help to make a stronger link in the chain.
Therefore she urged that "every student should be really educat-
ed and not nominally." The College Catalogue of 1884, she
wrote at the request of the faculty, and in it she called attention
"to the work in the pharmacological, chemical and histological
laboratories," an unusually advanced feature in a medical col-
lege of this time.

Dr. Jacobi always held the attention of her audience not only
by the content of her lecture or address, but also by her delivery.
Her manner was animated; she made no unnecessary gestures
nor did she use oratorical methods. Her voice carried well, her
face was expressive, illuminated; her eyes large, brown, often
twinkling with himior. ^

A Thursday morning clinic in the diseases of children was
given by Dr. Jacobi in the old college, primarily for the second
and third year students ; others could and did attend. An acute
gastric catarrh in its differential diagnosis carried the student
through the whole domain of medicine. Every device either in
making a diagnosis or in treating the patient was presented.

The necessity for providing adequate medical opportunities
for graduate physicians unable to attend the courses given in the
universities of Europe had received much attention by the facul-
ties of the medical schools in New York. In this medical problem
Dr. Jacobi was greatly interested. The faculty of the Women's
Medical College had considered the question, especially in its
relation to women. Dr. Jacobi had been appointed in 1880,^
by the faculty to form a plan for post-graduate instruction in
connection with the college and infirmary. The opening of the

' Elizabeth M. Cushier's Mary Putnam Jacobi Memorial Meeting Address.
' Martha Wollstein, M.D. 3 June 25, 1880, Faculty minutes.

xxii Mary Putnam Jacobi

New York Post-Graduate Medical School, admitting women
equally with men, made unnecessary any further efforts in this
direction by the Woman's Medical College. "In 1882, a school
was opened for post-graduate instruction in New York, and Dr.
Putnam Jacobi was invited to a place on its faculty, as the clinical
lecturer on children's diseases, the first time a lectureship in a
masculine school was ever, in this country, filled by a woman." '
The instruction was clinical, accompanied by charts, maps and
microscopical and gross pathological specimens, illustrating the
case exhibited. Dr. Jacobi's opening lecture on Diseases of
Children was given in a room crowded with men, few women
being present. The innovation of clinical teaching necessitated
the procuring of patients for presentation. This required the
education of dispensary patients. (The Post-Graduate School
at that time had neither dispensary nor hospital.) Patients at-
tending clinics controlled by colleges understood that they might be
used for demonstration before the students. Dr. Jacobi's patients
were sent from her large clinic at the Mount Sinai Hospital
dispensary. These patients could not understand and frequently
resented being sent to another clinic for this purpose. The most
important cases were brought (at times forcibly) by the clinical
assistant. Always instructive, the lectures were well attended.

The Association for the Advancement of the Medical
Education of Women

Mary Putnam Jacobi, Founder, 1872
President, i 874-1903

Objects: To raise the standard of the medical education of women.
"Article III. For this purpose it shall
I. Create an adequate fund

II. Apply this fund to the proper development of the course
of instruction at the Woman's Medical College of the
New York Infirmary." '

In 1878, "through the influence of the Association, the term
of study (in the college) has been extended to three years and the
sessions of each year increased to eight months, and preliminary

■ "Women in Medicine" in Woman's Work in America.
" Constitution of the Association for the Advancement of the Medical
Education of Women, 1874.

Physician, Teacher, Author xxiii

examinations are required of students at entrance. The school
is the only one in the country, with the exception of Harvard,
where these conditions are exacted." "Two additional pro-
fessorships have been supported, and a library founded." ^
"The assistance of the public is invoked to remedy an injustice
which the public has tolerated — that of depriving human beings
of the right to educate themselves. Every woman in America
who has tried honestly to fit herself for the duties of a physician
has been crippled by the organized, almost armed resistance
opposed to her efforts to obtain an education." "The real cost
of instruction, however, cannot be reduced except by diminishing
its real value; for its main expense is that required for the brains
of its teachers. At the present day the marked value of intellect
is such that the highest instruction cannot be obtained except
at an expense far beyond private resources. Intellectual values
represent the accumulated wealth of many generations. It is
impossible that any single generation should pay for them." ^
The report for 1883 deplores the fact that the association has not
succeeded in securing a suitable building for the college. "A
building is to a school what a body is to a soul. It may be more
imposing than the mental work accomplished and then it is a
disadvantage; but it may be so shabby as to depress the spirit
of the work and so alienate support from it, and such is otir
present case." ^ "Health is like the silent existence of those
happy nations that have no history. But disease represents the
commotion, the storm and stress, the drama and the convulsions
into which the disturbed history of our race has usually been
thrown." "We aim to exactly supervise the work of every
student and to lead each into the knowledge and habit of daily
intimate contact with nature, first in health, then in disease."

In a report read at Lakewood, 1884,'' Dr. Jacobi speaks of
some of the students as follows:

"It may interest you to know a few details about some of our students.
We have always had a certain number who were studying medicine for the

' President's Report, 1878.

'Our Future Aims, by Mary Putnam Jacobi, M.D. Address delivered
at Union League Hall, March 26, 1878.

3 Report of President, Mary Putnam Jacobi, M.D.

4 The School of Medicine for Women of the New York Infirmary. Paper
read at Lakewood, March 3, 1884.

xxiv Mary Putnam Jacobi

puppose of becoming missionaries in China and India. The fact that in these
countries the women are not allowed to be treated by men physicians at all,
offers an obvious field for women. One of our most intelligent graduates
has been established for some years in China, has a large practice there,
and is at the head of a large hospital. In this she is surgeon as well as
physician, and has performed many important operations. This year we
have a young Chinese girl as a student — the adopted daughter of an Ameri-
can missionary, who has given her a most careful general education. She
is extremely intelligent. The majority of our graduates of course settle
down at home, scattered through country towns, rather than in large cities.
Several have the largest practice of any of the half-a-dozen physicians in the
place. . . .

"While speaking of the students who have made, within otar circle at
least, some little mark, I must not omit to mention one, who is at present
most arduously engaged as physician to the out-practice of the Infirmary.
This is composed of the sick who cannot come to the dispensary or be received
in the hospital, but must be visited at their own homes. Our hard-working
out-door physician receives no salary save her board and lodging; but the
energy, fidelity, and conscientiousness with which she attends to her laborious
duties could not be purchased for gold. Her district extends from 14th to
Houston Street, and from 2d. Avenue to the East River. She often makes,
on foot, twenty, or even thirty visits a day to houses scattered far apart
through this large district ; and does not hesitate to go far down-town if a case
presents itself that peculiarly appeals to her interest or sympathies. Where
the salaried physicians attached to the city dispensaries would make, grudging-
ly, one visit a day or less, this girl will not hesitate to retixrn two or three
times in the twenty-four hour^, if she thinks that the case requires careful
watching. She will pass hours in the garrets or cellars of wretched tenement-
houses, absorbed in caring for the victims of frequently infectious diseases,
and often rendering personal services that the attendants are too ignorant or
clumsy to bestow. I shall never forget one case of a little child with diph-
theritic croup, upon whom, one midnight last winter, I operated at her request.
The child lived in a tenement in Canal Street, more than a mile from the
Infirmary. But for ten days the young doctor visited it every two or three
hours, and several times passed the entire night by its bedside. With every
day that elapsed after the operation, the first faint hope of saving the child's
life grew stronger, although in the vast majority of cases such children always
die; but the prolongation of life was remarkable, and the young doctor's
anxiety and enthusiasm grew constantly more intense. But finally she came
to my house early one morning, and burst into tears.

'"The child died last night,' she exclaimed. 'It was dreadful. I wish I
were dead too ! '

"Perhaps you will call this feminine nerves!

" I might continue to multiply instances of pluck, endurance, intelligence,
and heroism from the annals of our institution. But I must not exhaust
your patience. And I wish to return to the cardinal point of my subject:
the reason, namely, why I bring it at all before you, who are not medical stu-
dents, nor interested in medicine."

Physician, Teacher, Author xxv

In 1885, the name was changed to The Women's Medical
Association, as the name hitherto used is somewhat inconven-
ient.^ In May, 1899, the college closed. At a special meeting
of the Women's Medical Association of New York City, of which
Dr. Mary Putnam Jacobi was president, and at whose home the
meeting was held, March 31, 1903, the disposition of the fund
unexpended was proposed to be given to the Women's Medical
Association. A committee was appointed to arrange the legal
conditions necessary for the transference of the money which
was accomplished at the annual meeting. May 20, 1903.^

Author

" Not he is great who alters matter, but he who alters my state of mind. " —
The American Scholar, Emerson.

"Books are not absolutely dead things, but do contain a progeny of life
in them to be as active as that soul was whose progeny they are ; nay, they do
preserve as in a vial the purest efficacy and extraction of that living intellect
that bred them." — Milton.

The literary work of Dr. Mary Putnam Jacobi began in her
ninth year as stories and essays, expressed in a childish vein, but
nearly always in language with a trace of natural eloquence.
Her education had been fragmentary. During her earlier years,
instruction had been received chiefly from her mother, whose
method was to make the little girl read aloud good literature,
much reading of nothing but the best and a clear knowledge of
the Bible being her substitute for modern training.

Her first published story, entitled "Found and Lost," ap-
peared in the Atlantic Monthly, April, i860, and for it she re-
ceived eighty dollars. To "supplement her income" while
studying in Paris, she wrote for her father's magazine, Putnam's
Monthly, for the Atlantic Monthly and for Scribner's. One of
these articles, "Some of the French Leaders: The Provisional
Government of the Fourth of September," published in August,

'Report for 1885.

' Minutes of the Women's Medical Association, March 31, 1903; May 20,
1903. The Women's Medical Association was organized when the college
closed in 1899, and was composed of the members of the alumnae association
of the Woman's Medical College of the New York Infirmary (organized in
1870) and associate members.

An address delivered before this association will be found on p. 494 • The
first page has been lost.

xxvi Mary Putnam Jacobi

1 87 1, is described by Richard Watson Gilder as "one of the
ablest ever printed in an American magazine." Thirty-six years
later, Mr. Gilder declared,

"I have just been looking again at that article; and bearing in mind all
the essays that have appeared in all the magazines which have sprung up,
stayed up, and passed down since, and not being sure, either, whether or not,
all its conclusions will bear the test of time, I still am inclined to think this
same essay is 'one of the ablest ever printed in an American magazine.'" '

Eight of these stories and sketches have been collected in a
volume. Of these, four shov^^ the influence of her medical studies ;
one, "A Model School," ^ written in 1870, describes what would
be considered today (1924) a school in advance of this time in
caring for the health and education of babies and children under
fourteen years of age. The last essay was written during the
siege of Paris, August, 1871.^

After her return from Paris, Dr. Putnam's literary work was
devoted to medical subjects or to those relating to women in
medicine, with the following exceptions: "Physiological Notes
on Primary Education and the Study of Language"; "The Value
of Life," a reply to Mr. Mallock's essay, "Is Life Worth Living,"
1879; "CommonSense Applied to Woman Suffrage," 1894. The
first essay relating to women in medicine is entitled, "Shall
Women Practice Medicine?" published in the North American
Review, in Jan., 1882. "Women in Medicine," " the most able
study yet written of the struggle and final triumph of women in
entering the study and practice of medicine. The first para-
graph reads:

"The history of the movement for introducing women into the full practice
of the medical profession is one of the most interesting of modern times.
This movement has already achieved much, and far more than is often sup-
posed, yet the interest lies even less in what has been so far achieved, than in
the opposition which has been encountered: in the nature of the opposition;
in the pretexts on which it has been sustained, and in the reasonings, more or
less disingenuous, by which it has claimed its justification. The history,
therefore, is a record not more of fact than of opinion. And the opinions
expressed have often been so grave and solid in appearance, yet proved so

' Mary Putnam Jacobi Memorial Meeting Address, by Richard Watson
Gilder.

' "Concerning Charlotte."

3 Stories and Sketches, by Mary Putnam Jacobi, 1907.

<" Women in Medicine," in Woman's Work in America, 1891.

Physician, Teacher, Author xxvii

frivolous and empty in view of the subsequent event, that their history is not
unworthy of careful considerations among that of other solemn follies of man-
kind."

Dr. Putnam Jacobi's writings and work for women were
mainly devoted to endeavoring to obtain for the qualified woman
undergraduate admission to the best medical schools. Largely
because of her efforts, Johns Hopkins Medical School opened its
doors to women. A world war presented the opportunity to
women for admission to any college of their choice, except
Harvard, the first to be appealed to in 1847, and in 1924, still
closed. In 1891, Dr. Jacobi wrote, "Unless all the opportunities,
privileges, honors, and rewards of medical education and the
medical profession are as accessible to women as to men, women
physicians cannot fail to be regarded as a special and distinctly
inferior class of practitioners." '

Her first medical writings were letters from Paris to the
Medical Record, in 1867, entitled "Medical Matters in Paris,"
signed P. C. M., and were written to "supplement her income."
Later ones include lectures, addresses, editorials and scientific
papers, some read before societies, two written for the Cyclopcedia
of Diseases of Children, two for Pepper's System of Medicine.
She was specially interested in the problems of neurology.
Hysteria, the subject of several of Dr. Jacobi's papers, has
received renewed attention during and since the World War.
Of this she wrote in 1 886 :

"Notwithstanding the voluminous literature which exists on hysteria,
something always remains to observe and describe in it. And this is to be
expected when it is remembered that hysteria implies disarrangement of the
functions of any part of the nervous system in its four spheres of intelligence,
mobility, sensibility and visceral neurility. Every advance in our knowledge
of these mysterious functions must, therefore, lead to some new point of
view in regard to hysteria." '

In 1876, Dr. Jacobi wrote the answer to the question, "Do

women require mental and bodily rest during menstruation, and

^ to what extent?" For this she was awarded the Boylston Prize

' of two hundred dollars from Harvard University for the year

1876.

' "Open Letters," The Century Magazine, February, 1891.
* Essays on Hysteria and Brain Tumor, ajid some other cases of nervous
disease, 1888.

MEMBER OF MEDICAL SOCIETIES

"Let us be wise, and not impede the soul. Let her work as she will.
Let us have one creative energy, one incessant revelation. Let it take what
form it will, and let us not bind it by the past to man or woman."

— Margaret Fuller, 1844.

New York County Medical Society

Medical Library and Journal Association

New York Pathological Society

New York Neurological Society

Therapeutical Society of New York

New York Academy of Medicine

Alumnae Association of the Woman's Medical College of

Pennsylvania
Women's Medical Association of New York City

The story of the struggle of women to obtain official recogni-
tion as physicians by admission to the medical societies, Dr.
Jacobi relates in Women in Medicine. The first application by
a woman was made in 1859 to the Philadelphia County Medical
Society and was refused. The long struggle ended successfully
in that state in 1888. In Massachusetts, in i860, Dr. Marie E.
Zakrewska applied for admission to the State Society and was
promptly refused. The struggle was long and bitter, ending in
triumph for the women in 1879. In New York State, admission
to the County Society met with no opposition. Dr. Emily
Blackwell, the first woman, was admitted June 5, 1871; Dr.
Mary C. Putnam, November 27, 1871. Dr. Abraham Jacobi
tells the story in his Presidential Address of December, 1871.

"Concerning our recent admission, I have another remark to offer. It
is not a small satisfaction to me that, in this year of my presidency, one of
the most urgent questions of the day should have been quietly and noiselessly
answered. The admission of females into the ranks of the medical profession
or rather — as their obtaining the degree of M.D. is a matter belonging to

Member of Medical Societies xxix

chartering legislatures and their obtaining a practice depends on the choice
or prejudice of the public — into the existing medical societies, has been decided
by you by a simple vote not attended either by the hisses and clamors of
excited young men in medical schools or by the confusion and degradations
of the meetings of a medical association. I think we can say that our action
has finally settled a question, the importance of which was recognized by
everybody. The vote of the largest society of the kind in the Empire State
and I believe in the Union will have the effect of soothing the passions and
leveling prejudices in the circles of the army of medical men, 40,000 strong
in the United States, and of raising us in this respect to the standard of Euro-
pean countries. Even the conservative seat of learning, Edinburgh, has
admitted women to medical studies. Paris has turned out a woman doctor
of medicine who will prove, I hope, none of the least ornaments of this society,
the profession of this city, and our common country."

"Entree into the New York Academy of Medicine in virtue
of special medical work that I have already laid out," thus wrote
the enthusiastic Paris student to her mother, January 13, 1870.
The desire expressed in this letter was not attained until 1880,
when she "was elected, though by the close majority of one to
membership in the New York Academy of Medicine, the first
woman to be admitted. . . . She was excluded from the Obstetri-
cal Society by means of blackballs, although her paper as can-
didate was accepted by the committee on membership and she
received a majority vote." ^ The first medical society to which
Dr. Jacobi was admitted was the Medical Library and Journal
Association soon after her return from Paris. It was at a meeting
of this society that she for the first time participated in a medical
discussion. In 1873, she was admitted to the New York County
Medical Society. She was the first woman sent as a delegate
from the County Society to the New York State Society, in 1874.
Her paper (page 284) was the first presented by a woman at a
meeting of the New York State Medical Society. The New
York Pathological Society admitted Dr. Jacobi in 1871, and at a
meeting on February 14, 1872, she presented her first specimen.
Dr. Wyeth, at one time president of the society, writes in 1914,
of the meetings .

"Dr. Mary Putnam Jacobi, whose knowledge of pathology was so thor-
ough, whose range of the literature was so wide, and whose criticism was so
keen, fearless and just, that in our discussions we felt it prudent to shun the
field of speculation and to walk strictly in the path of demonstrated facts." »

' Women in Medicine, Dr. Mary Putnam Jacobi.
' With Sabre and Scalpel, John Allen Wyeth.

XXX Mary Putnam Jacobi

"She was a regular attendant at the Neurological Society." "She spoke of
the papers read, always with interest, and always with point and brevity . . ."
"It was a just recognition of her ambition, that she was finally made chair-
man of the Section on Neurology of the New York Academy of Medicine." '

She also became a member of the Therapeutical Society. She
was a member and president of the Alumnae Association of
the Woman's Medical College of Pennsylvania. With the closing
of the Woman's Medical College of the New York Infirmary, in
1899, the Alumnae Association of the college, of which Dr. Jacobi
was an honorary member, became the Women's Medical Asso-
ciation of New York. This association she helped to organize
and served as president.

Dr. Mary Putnam Jacobi died on June 6, 1906. At the age
of ten, she wrote to her grandmother :

"Vague longings beset me. I imagine great things and glorious deeds;
but Ah! the vision passes like a fleeting dream and the muddy reality is left
behind. I would be great. I would do deeds, so that after I had passed into
that world, that region beyond the grave, I should be spoken of with affection,
so that I should live again in the hearts of those I have left behind me."

Looking back upon her life and the things that she accom-
plished, we can only say that she did become great, that she did
deeds for which she is spoken of with affection, and that she lives
again, and forever, in the hearts of those who knew her.

She has joined "the choir invisible
Of those immortal dead who live again
In minds made better by their presence:
In thoughts sublime that pierce

The night like stars
And with their mild persistence urge
man's search

To vaster issues."

' Mary Putnam Jacobi Memorial Meeting Address, by Dr. Charles L.
Dana.

MARY PUTNAM JACOBI

Dr. Mary Putnam Jacobi began her medical writings in
letters from Paris to The Medical Record. They ran from 1867
when she was 25 years old to 1871, when she graduated. They
gave a very accurate picture of the medical and surgical activi-
ties of this time, with occasional personal touches that enlivened
her very conscientious descriptive work. These letters still
possess interest and have a definite historical value.

When she had established herself in practice in New York
she began at once to publish medical articles and she continued
to do this yearly in the form of reports, pathological records,
addresses and reviews until in 1900 when her final illness over-
took her.

At the beginning the subjects of pathology and pathological
anatomy especially, interested her. She probably realized that
a young doctor with little clinical experience was best fitted to
contribute concrete things like pathological specimens about
which there would be little question of opinion. She, however,
early showed an interest in therapeutics; and this interest was
emphasized by her appointment as Professor of Materia Medica
and Therapeutics in the Woman's Medical College.

I find in her writings about 50 contributions to pathology;
20 to neurology, about the same number to pediatrics, a dozen
contributions to physiology and an equal number to education.

Dr. Jacobi's contributions to medicine were always made with
great care. They showed familiarity with previous work and a
keen desire to add something definite to human knowledge
through her own observations. She quite often brought her
special knowledge of social life and of educational problems into
her medical investigations. Running through her writings
appears her ambition to secure equal rights for women in medi-
cine and in the state, and it is due not a little to her that eventual •
ly such rights have been secured.

xxxii Mary Putnam Jacobi

Dr. Jacobi added many clinical and pathological and educa-
tional facts which still remain valuable to her chosen science.
She will be remembered by these and also by the example of her
courageous and path-breaking career and by her success in pro-
moting the elevation of woman's status as contributors to science
and as efficient members of a learned profession.

—Charles Loomis Daxa, M.D.

MARY PUTNAM JACOBI

LETTERS TO THE MEDICAL RECORD, 1867— 1870—
MEDICAL MATTERS IN PARIS. SIGNED P.C.M.

To the Editor of the Medical Record.

Sir — In Paris, the absence of the excitement afforded by
political elections is amply compensated, for a limited circle of
people at least, by the continually recurring elections at the
Academy, and nominations at the concours. You are aware
that all the hospitals in Paris are under the control of a central
administration, who appoint all the physicians. The appoint-
ment is made by the decision of a jury, drawn by lot, from among
the actual hospital physicians, who decide the merits of the
various candidates for a vacancy, after submitting them to
severe clinical examinations. A concours of this kind has just
terminated, in a manner infinitely disappointing to fifty of the
candidates who were rejected, and highly agreeable to the two
who were deemed worthy for the important position. The
successful candidates were MM. Olliver and Praust.

A new contest is now going on at the Academy, which is
busy in deciding upon nominations to the chairs of surgery and
medicine, left vacant by the death of Jobert and Rostan. Among
the foremost candidates for the first position is M. Langier, who
has recently added to his previous claims to distinction by an
exceedingly interesting memoir upon cerebral concussion. The
phenomena occasioned by this accident are analyzed with the
greatest care, and referred to that part of the encephalon which,
according to present physiological ideas, presides over the func-
tions compromised. The cerebral hemispheres are certainly
affected, for the intelligence, all voluntary and affective faculties,

2 Mary Putnam Jacobi

and the consciousness of all sorts of nervous irritation, are en-
tirely suspended. Unconscious sensibility, on the contrary, and
all movements resulting from reflex action, are, however, pre-
served, which proves that the pons arolii, and probably the
corpora striata and thalami optici are in all their integrity. M.
Langier discusses the question, why the hemispheres alone should
suffer from a shock that must be transmitted to them through
portions of the encephalon that remain uninjured. He accounts
for this immunity on the part of the pons, the bulb, etc., by the
fact of their superior firmness of structure, and the more secure
position of their gray masses, which, being in the centre of the
white tissue, are much less exposed to shock than the gray sub-
stance of the hemispheres distributed over their surface.

It is not certain whether this memoir will elect M. Langier,
but it is discussed in his favor. Another illustration of the value
of disease in dissecting apart the involved functions of the brain,
is furnished us this week by a most interesting case at the Hopital
St. Antoine, in the service of M. Jaccaud. It was a case of
aphasia, the disease that has been rendered so famous by M.
Broca's theory, which attaches it to a lesion of the third anterior
convolution of the left cerebral hemisphere. The accident is
not uncommon, but the opportunity for verifying the diagnosis
by an autopsy is comparatively rare, as the disease is rarely or
never directly fatal. Hence this case, which afforded such an
opportunity, is one specially valuable.

The patient in question was already a victim to Bright's
disease of the kidney, for which he had been in the hospital since
last June. At the period of the accident he suffered from an
extensive oedema, without ascites; albumen was abundant in the
urine; he presented, moreover, a systolic souffle at the point of
the heart. On the 226. of January, without any premonitory
symptoms, this patient suddenly discovered that he had lost the
power of speech, and on the morning visit, the next day, he was
found in a state of great disquiet, pointing to his lips and tongue,
indicating by signs that he wished to speak but could not. There
was not the slightest lesion of any of the limbs, and at the face
only a slight paralysis of the zygomatic and elevator muscles of
the right side of the mouth, which was drawn a little to the left.

The understanding was not in the least impaired ; he took up
any article that was named to him, but could not name them

Letters to the Medical Record 3

himself. When a person pronounced before him a word distinctly
articulated, he examined carefully the motion of the lips, and
succeeded in uttering some monosyllable, as "bien," "vous,"
but that was all. He was equally unable to write as to speak,
never getting beyond the first letters of his name.

In presence of these symptoms, and on account of the mitral
insufficiency, M. Jaccaud pronounced a diagnosis of lesion of the
third frontal convolution, probably at the left (since that is the
case seven times out of ten), and probably in consequence of an
embolus.

The aphasia began to disappear by the end of the 30th, and
by the end of February was entirely gone. The patient died on
the 22d of April, and at the autopsy the diagnosis was fully
confirmed by the discovery of — first, complete fatty degenera-
tion of the kidneys; second, vegetations on the mitral valve, and
insufficiency; third, buried in the white substance of the third
frontal convolution of the left hemisphere were two haemorrhagic
cysts, which contained some drops of liquid. One of these cysts
was the size of a pea, and situated at the right of second, whose
volume was three times as considerable. The surface of the
section was distinct and well limited; not only the lesion did not
extend beyond the convolution in question, but the gray matter
of that was untouched, and from the exterior appeared perfectly
healthy. The other parts of the encephalon, as also the mem-
branes and the arteries, were examined with great care, and
found perfectly sound.

Hence this case brings fresh support to the theory that places
the power, not merely of speech, but also expression by writing,
in this limited part of the brain.

Among the candidates for the vacant place in medicine at
the Academy, M. Hdrard is one of the most prominent. His
claims to the honor chiefly rest upon a work that he has published
this year upon pulmonary consumption. The initial idea of this
striking book was originally promulgated in Germany by Rein-
hardt, but M. Herard and his colleague, Cornil, have done much,
not merely to popularize Reinhardt's views, but to bring to their
support abundant clinical demonstration. You are aware that
Reinhardt completely upsets the old descriptions given by
Laennec and Louis of the cheesy tubercle. According to recent
microscopical researches, the yellow masses thus denominated

4 Mary Putnam Jacobi

are formed, not by the ulterior development of a heterologous
deposit, but of a pneumonia, excited by the presence of the crude
tubercles in the connective tissue of the lung. This pneumonia
differs from ordinary acute pneimionia, rather in its anatomic
and microscopic characters, than in its constitutional effects.
Instead of an exudation of fibrine into the alveoles, there is an
exudation of pavement epithelium and leucocytes. In other
words, it is a catarrhal pneumonia, similar with that caused by
artificial experiment. To this pneumonia Herard and Cornil
refer all the general symptoms of phthisis, the fever, emaciation,
and destruction of the vital forces. They maintain that the
presence of the crude tubercle in the lung excites no general dis-
order, and it may remain latent for an indefinite period, until,
generally in consequence of some special accident, the tissue
surrounding it inflames. This inflammation may subside spon-
taneously or under the influence of treatment, but relighted
again and again, it finishes by entering upon the cheesy state
(pneumone caseuse). At this stage the contents of the alveoles
liquify, the hepatised lung softens, and the cavern is formed
which for so long has been exclusively attributed to the softening
of the tubercles. These also soften, but their size always re-
mains the same as that of the original gray granulation. Even
when softened they may be distinguished from the masses of pneu-
monic lung through which they are disseminated, by the presence
of small nuclei and the cellules, called by Robin cytoplastians.

In consequence of this view of the anatomy of phthisis
(which approaches in its nature somewhat to that proclaimed
by Broussais), M. Herard lays special stress upon local revulsives
in the treatment, iodic frictions, blisters, and the actual cautery.
The tonic and stimulant general treatment is of course also
maintained, though our American use of alcohol is rejected. To
a certain extent, a moderate use of tartar emetic, as recommended
by Foussagrines, is counselled.

This treatment does not procure brilliant results in the
hospitals, where the patients generally are too far advanced to
be saved, but M. Herard declares that a fair share of success
may be obtained in private practice, where the disease is treated
at the very beginning.

M. Marriothe communicates to the Bulletin de ThSrapeutigue,
an account of some clinical experiments made by himself this

Letters to the Medical Record 5

winter with muriate of ammonia, in the treatment of catarrhal
fevers that have been epidemic in Paris. These fevers assumed
a remittent or intermittent type, without losing their distinc-
tively catarrhal character, but proved quite obstinate to sulphate
of quinine. In accordance with a suggestion by Schmidtmann,
who was in the habit of giving muriate of ammonia in the declin-
ing period of gastric fevers when they assumed a periodical form,
M. Marriothe tried the experiment, at first in some cases com-
plicated with very severe neuralgies, which interrupted sleep, and
even extorted cries from the patient. The effect of the muriate
was surprising. In mild cases the febrile attacks and the neural-
gies ceased upon the first or second day ; in more severe forms the
success was not complete till the third or fourth, but there was
always amelioration by the first or second.

M. Marriothe thinks that the salt has an important influence
in moderating the erethism of the mucous membranes, but that,
besides, it acts directly on the nervous system, without the occur-
rence of any intermediate phenomena, as vomiting, sweating,
diarrhoea, etc. The dose found necessary to arrest the febrile
attacks and cahn the neuralgia, varied from thirty to sixty grains
in the course of the day, being administered in portions of 7-15 5
every three or four hours.

An operation that Dr. Brown has done much to bring into
favorable notice in England, is beginning again to excite the
attention of French physicians. I mean the capital operation of
ovariotomy, upon which M. Boinet has just read an elaborate
report before the Academy. The report begins with reference to
an American, the first who practised ovariotomy with the definite
intention of extirpating the diseased organs. Dr. Ephraim Mac-
Dowell, of Kentucky. This surgeon, between 1809 and 1830,
operated thirteen times, and obtained eight cures. Baker Brown
reports twenty-nine successful cases out of thirty-two operations.
Even were the success in much smaller proportion than this (and
the recent expose of Brown's character renders us cautious about
accepting his statistics), the operation would be legitimate in a
disease that conducts its victims almost inevitably to the grave,
the deaths being 95 in 100. M. Boinet reprobates the timidity
of the French surgeons, who have so long recoiled before this
operation, and proceeds to give many useful hints upon the pre-
cautions necessary to insure success.

6 Mary Putnam JacobI

In the first place, the operation should never be performed
at a hospital, where peritonitis invariably follows the opening of
the abdomen; a healthy, isolated locality should be selected, and
a room prepared whose temperature should be maintained at 20
to 25 degrees centigrade. Secondly, the nature of the cyst must
be carefully considered. If it be simple, unilocular, containing a
liquid, clear, limpid, and serous, or even purulent or sanguinolent,
the operation is inappropriate. Nelaton's system of iodine injec-
tions should be first tried. But if the liquid, though at first
serous becomes unctuous and fatty, ovariotomy is the only
resource. Other proofs that the cyst is multilocular, or that it
contains pathological productions contra-indicating the use of
iodine, signs of the increase of the tumor, and exhaustion of the
patient, are circumstances that should also call for the operation.
Among the contra-indications should be reckoned the existence
of grave complications, an early stage of the disease, pregnancy,
or tumors in the uterine walls.

The operator should place himself at the right or left side of
the patient, instead of between the knees, as recommended by
some surgeons. The incision should be made on the median line,
and of sufficient size to admit the free introduction of the hand
in the cavity, for the purpose of recognizing the size and position
of the tumor and the extent of the adhesions, which exist three
times out of four. When these adhesions are slight and can be
easily torn, they occasion no inconvenience; but if large and
resistant, their action frequently causes dangerous haemorrhage.
The dangers of too short an incision have been frequently ex-
posed; the adhesions are not distinctly perceived, the cyst is
imperfectly grasped, the other ovary cannot be seen, the pedicle
is tied with difficulty, and sanguineous effusions may take place
in the abdominal cavity without the knowledge of the surgeon.
Should the first incision prove too short to avoid these incon-
veniences, a second can always be practised with safety.

The incisions should divide the different layers of the abdom-
inal wall in succession, to avoid too sudden entrance into the cyst.
As soon as this is discovered, the hand should be introduced, to
ascertain the existence of adhesions or neighboring tumors. In
the second case, it is only necessary to enlarge the incision ; in the
first, the adhesions must be detached by the hand, or destroyed
by the scissors or hot iron. They should not be torn.

Letters to the Medical Record 7

Before tapping the cyst two assistants should press upon the
abdominal walls, in order to force the cyst to project between
the lips of the incision. The puncture is then made with a trocar,
and by means of the foregoing precaution the liquid is prevented
from running into the peritoneal cavity. If there is more than
one pouch, the first should be held by pincers, or tied, while the
others are drawn out of the cavity. If the cyst, on its retreat,
draws a portion of its adherent intestine, it is important that this
be detached ; if that be impossible, a piece of the cyst must be cut
out, and left attached to the intestine. Care must be taken, how-
ever, to remove the internal secreting membrane from this fragment.

All bleeding vessels, whose volume is not too considerable,
should be twisted, or cauterized with a hot iron or the perchloride.
Only when this method is impossible should the vessels be tied.

The wound should not be closed until the last drop of liquid
has ceased to flow. An eminently useful precaution consists in
placing in the inferior angle of the wound, or in the recto- vaginal
cul-de-sac, a caoutchouc tube, by which any liquid subsequently
effused may drain off. MM. Keith and Koeherle attribute a
great number of their successes to the observance of this pre-
caution. Boinet has no dread of the introduction of air into the
peritoneum, attributing all inflammation to the action of liquids,
and not air.

A double line of sutures is necessary, one deep, the other
superficial. M. Boinet decides in favor of including the peri-
toneum in the suture, to avoid the danger of this membrane
contracting adhesions with the intestine. The pedicle should be
compressed by a toothed clamp, which has the advantage of
compressing the tissues and preventing heemorrhages. If the
pedicle is voluminous, it should, however, be tied, or the liga-
ture combined with the clamp. When the size of the pedicle, or
its insertion on the uterus, presents unusual difficulties, a thread
of ligature should be passed around it before the cyst is cut away.

M. Boinet concludes,

" that the ovariotomy should be accepted with as much enthusiasm as all other
capital operations ; and that now that the bases of diagnosis are better assured,
and the operative procedures more perfect, the subsequent treatment better
understood, more advantageous results will doubtless be obtained."

M. Demarquay, surgeon of a Maison de Sante, presents a
report on the topical application of iodoform in the treatment of

8 Mary Putnam Jacobi

cancer of the uterus. This agent employed in the crystalline
form, in a dose of 7 to 15 grains, is mixed with a sufficient quan-
tity of butter of cocoa, and the suppository thus formed, intro-
duced into the vagina, or an ulceration of the carcinoma, if that
exists, — a tampon of cotton is placed in front. The general
effects are slightly observable, although the iodine from the
drug (C^HP) is absorbed and may be discovered in the saliva
and urine. But the local suffering is almost infallibly soothed;
the swelling of the abdomen diminishes; and the ease procured
lasts as long as the medicament is continued, is broken up by
the interruption of its administration, and reestablished when
that is renewed.

Dr. Morel, the distinguished alienist, writes an interesting
article in the Archives of Medicine for May, upon progression in
hereditary insanity and nervous diseases. Not content with the
vulgar fact of hereditary influence in the transmission of such
disorders, he, in company with an army of modern confreres,
seeks the laws that govern this hereditary transmission. I have
not space left to enter into all the details of his curious paper,
I can only mention three or four of the most striking conclusions,
drawn from a great number of facts; ist. Insanity, epilepsy,
hysteria, chorea, eccentricities, dypsomania, etc., are only the
branches of an identical constitutional vice of the nervous sys-
tem, and may be transformed, the one into the other, by way of
hereditary transmission. 2d. Such transformation is more fre-
quent than the transmission of the same form of disorder. When
a simple eccentricity of a parent becomes insanity in a child, &c.,
the hereditary taint is said to be progressive ascendant, and the
opposite case progressive descendant. 3d. Whenever the sev-
eral children of parents presenting a nervous taint, are markedly
dissimilar in appearance and character, the taint will almost
surely be transmitted, and progressive ascendant. It seems in
this case as if the whole force of family likeness was concentrated
in the depths of the nervous system. 4th. In such families it is
common to observe that one or more of the members are gifted
with remarkable intellectual ability, while others are idiots.

The third proposition especially constitutes the theme of
M. Morel's present paper. The fourth identifies his views with
those of Dr. Moreau, who, in his remarkable work on morbid
psychology, unhesitatingly ranks genius among the neuroses,

Letters to the Medical Record g

and assigns to it an origin identical with that of epilepsy, in-
sanity, and idiocy.

Paris, Tune 1 8, 1867.

P. C. M.

To the Editor of the Medical Record.

Sir — At the last seance of the Academy of Medicine the
discussion on tracheotomy was continued, and M. Peter made
quite a discourse on the subject, describing the practical dif-
ficulties in the way of the operation, and suggesting means of
overcoming them. Among the principal, is the small size of
the trachea in young children. The operator is liable, in making
an incision with the bistoury directed perpendictdarly to the
windpipe, to pass completely through that organ to the oesopha-
gus. Again, the index-finger used to hold the trachea in place,
frequently pushes it to one side, so that the incision is made to the
right or left of the median line. This would be of small conse-
quence if the trachea was steadily maintained in the first position,
but too often the finger slips, the trachea returns to the middle
of the throat, and the incision is concealed from view. These
difficulties are more formidable as the child is younger, but M.
Peter thinks that the age alone never offers a formal contra-
indication, since it is well in case of need to operate on the smallest
child, and give it a chance for life at a moment that all others are
lost.

M. Peter considers, however, that tracheotomy is never
necessary, and therefore never advisable, except in cases of
pseudo-membranous croup, and believing that pseudo-mem-
branous angina invariably accompanies this disease, he abstains
from the operation whenever he cannot find false membranes
in the pharynx. The extension of the membranes to the bron-
chial tubes is, however, of course a circumstance of unfavorable
omen for the operation. It is often difficult to diagnose this
complication. M. Moutard Martin signalizes 'pale asphyxia as
an excellent sign. M. Peter adds, an unusual frequence of the
respiratory movements, whose rapidity is slackened in simple
laryngeal croup. Whenever there are more than fifty inspira-
tions a minute, there is good reason to suspect a pseudo-mem-
branous bronchitis.

10 Mary Putnam Jacobi

Subsequent to the operation, the practitioner possesses
another sign of this formidable complication. When the canula
left in the tracheal wound does not become filled with mucosities,
when at the end of twelve hours it is still dry, there is too good
reason to believe that the mucous surface of the bronchial tubes
is covered with false membranes which effectually prevent
secretion.

M. Peter declares that pseudo-membranous bronchitis is quite
frequent, occurring, in his experience, 52 times in 105 fatal cases.

Pneumonia coincident with the croup does not absolutely
forbid the operation. M. Grisolle observes, that his first success-
ful case of tracheotomy was embarrassed by this complication.
M. Nelaton had been called upon to operate, but recognizing the
concomitant pulmonary lesion, refused. M. Grisolle then as-
sumed all the responsibility, and operated himself — ^the child
recovered.

M. Archambaud had obtained 21 cures among 67 operations,
including two upon adults. The most of these cases had already
reached the last period when the operation was performed, the
patients sometimes being completely insensible. Among 53
operations made under such circumstances, 17 had succeeded, and
among 12 cases treated at an earlier stage of the disease, 4 were
saved. The proportion therefore is about the same.

M. Peter assumes as contra-indications, an excessive waxy
pallor, ganglionic engtjrgement, extreme puffiness of the neck,
which is neither oedema or emphysema, all signs of general in-
toxication.

Cases of stridulous laryngitis are successfully treated by M.
Peter with steam. The child is surrounded by half-a-dozen
basins filled with boiling water, so that the respiratory organs
may be incessantly bathed in the humid atmosphere ; the croupal
symptoms generally subside in about an hour.

The month of June has been unfavorable for the performance
of tracheotomy, since out of eight operations, divided equally
between the Children's Hospital and Hopital St. Eugenie, six
have proved fatal.

Appreciation of Medical Constitutions.

This observation enters into a report, presented by Mr.
Besnier to the Academy of Medicine, on the medical constitution

Letters to the Medical Record n

for June. An effort is being made just now to collect materials
for a rigorous appreciation of "medical constitutions." The
value of such an appreciation cannot be too highly estimated,
when it is remembered how largely this condition enters as an
element into the effect of medical treatment. There can be no
question, that the reputation of a large number of methods and
medicines has been made by the fact that they were administered
at a moment when the disease had assumed a benign type, and
tended of its own accord to a favorable issue. During this
month of June, nearly all the cases of typhoid fever in the hos-
pitals have recovered. There has not been less, but rather more
of the disease than usual, and the first stages have frequently
opened with considerable severity, but any dangerous symptoms
have quickly abated, and the course of the malady has been
equally satisfactory under any treatment. This reminds me of
an amusing anecdote related by Dr. Maximin Legrand m the
feuilleton of the Union Medicate:

One day, the gargon de service, employed in the wards of M. Fouquier,
appeared with two black eyes, and his face covered with bruises. "What is
the matter with you, my man? "inquired M. Fouquier, always kind and polite.
"I have been fighting with M. Bouillaud's infirmier, and he is better done for
than I am." "You were very wrong; what were you fighting about? " "Be-
cause he insisted that it is always necessary to bleed in typhoid fever!" The
gravity of the physician was not proof against this unexpected reply.

When it is remembered that M. Bomllaud is the author of the
famous system of bleeding in pneumonia twice a day, coup sur
coup, and extends his sanguinary propensities to typhoid fever
also, the belligerent enthusiasm of his humble subordinate may
be easily explained.

The Administration of Mercury in S3rphilis.

At the Imperial Society of Surgeons, the discussions still
turn upon the question of the administration of mercury in
syphilis, a question that seems subject to periodical agitation.
The most conspicuous part of the debate has been that sustained
by M. Despr^s whose views have been entirely special, "so
special," observes Dr. Reveillant, "that he remained entirely
alone in his opinion." For M. Despres is radical enough to deny
any efficacy to mercury whatever, in the disease in which it has
for so long been considered the sheet-anchor. He is resolved

12 Mary Putnam Jacobi

never to administer the baneful drug either in primary, or secon-
dary, or tertiary syphilis. Theoretically, he bases his prin-
ciples upon the idea, that the malady is already so exhausting to
the patient, that the debilitating effects of mercury can work him
nothing but injury. Practically M. Despr^s appeals to the
result of his experience in the Hopital Leourcine, among 234
patients, of whom some were subjected to the classical treatment,
others to a course of tonics. Among the first, a percentage of
28 for 100 returned after more or less time to the hospital for
fresh treatment of the disease, while in the second class the
returns were only 10 for a hundred. M. Despr^s declares, rather
fancifully, that the physician should endeavor to restore his
patient to a "life of infancy," regulating his food, sleep, and
exercise, building up his shattered constitution, and that nature
would eliminate the poison.

"We cannot believe that a purely empirical medicine can be a contra-
poison against syphilis, or that there is any sense in employing a drug that
exists in the blood like foreign matter, which does not assimilate with a single
fluid, and which, even in exercising a certain perturbating and deleterious
effect on the economy, neither solicits nor suspends the regular exercise of a
single function."

The only points of importance in M. Despres' remarks, are
the statistics, and their value is vigorously contested by M.
Depaul. He observes that the comparison between the two
modes of treatment was not sufficiently extended, and moreover,
that the basis of comparison was fallacious, since a number of
the patients who had been treated by expectation, probably
absented themselves from the clinique, not because they were
cured, but because they were disgusted with the treatment.
Nothing exasperates a hospital patient so much as the suspicion
that nothing is being done for him. He maintained that this
expectant system was extremely dangerous, since the most
serious destruction of tissue, such as the perforation of the pala-
tine vault, might take place while the physician was watching
with folded hands. M, Depaul laid especial stress on the efficacy
of mercury administered for syphilis contracted during pregnan-
cy, when, he declares, it uniformly prevents abortion, in recent
cases.

A case that recently occurred in the service of M. H^rard at
Laribaissiere, which I had an opportunity of observing myself,

Letters to the Medical Record 13

is in entire accordance with this assertion. The subject was a
woman of about 35, in the third month of pregnancy. Several
years previous she had been treated at Lourcine for primary
syphilis, and two years ago had been an inmate of Laribaissi^re
for syphilitic angina. Each time she had completely recovered,
and it was impossible to ascertain whether the renewal of the
disease was a manifestation of the original malady, or the result
of a new infection. At the moment of her entrance, in June, the
patient presented an eruption of syphilitic erythema, copper-
colored blotches disseminated over the entire body; a small
tumor on the right frontal bosse, with broad base, but slight ele-
vation, but the seat of lancinating pains exasperated at night,
and which extended also to the temples and the ears: a gray
ulcerated fissure at the left commissure of the lips; a grayish
plaque mugiieux on the right labium majus of the vulva. Fine
subcrepitant rales could be heard at the summit of the left lung.
A cough had existed for several months, but the patient professed
to have been perfectly free from syphilitic accidents at the com-
mencement of her pregnancy. She was ordered a pill of corro-
sive sublimate containing five centigrammes, to be taken every
evening. This was the nth of June. On the 12th, in addition
she commenced to take 25 centigrammes of iodide of potassium
every morning. By the 19th the pains in the head had entirely
ceased, and the eruption had begun to fade. By July nth the
tumor had almost disappeared, as also the plague muqueux, and
the eruption was entirely gone. The fissure of the lips was also
healed, and the patient left the hospital on the i6th of July in a
perfectly satisfactory condition (the cough also was diminished),
both as regards her general health and the march of the preg-
nancy. The treatment was continued uninterruptedly during
the first month ; after that, the sublimate was suppressed, and the
iodide alone continued.

MM. Guerin, Perrin, Verneuil, and Velpeau, also took up
arms in defence of mercury. They nearly all insisted upon a
prolonged treatment, not less than two years, as absolutely
necessary to radical cures. M. Guerin therefore disapproves of
large doses. He prefers the protiodide associated with opium,
but in case that is supported with difficulty, he has recourse to
fumigations with cinnabar. He does not believe that inunctions
alone are sufficient, while they have the inconvenience of pro-

14 Mary Putnam Jacobi

ducing salivation more speedily than other methods of adminis-
tration. M. Perrin, with an experience of 470 cases, treated at
Val de Grace, disbelieves that mercury administered in primary
syphilis can prevent the regular evolution of the disease, and
therefore confines himself to local cauterizations, and only
commences general treatment with the appearance of secondary
symptoms. He is careful to administer chlorate of potassa coin-
cidently with the mercury in any form. He acknowledges that
no treatment is infallible against relapses, but that the physician
is simply called upon to be perseverins^, and reapply the treat-
ment at each outbreak until he has mastered the disease.

M. Verneuil and Velpeau believe in the beneficial effects of
mercury at all periods of the disease, and the former declares
that salivation is an imaginary- phantom. Syphilis may exhaust
itself spontaneously, but such cases are rare, and generally the
patients are exhausted first.

The only person who in any way sustained the views of
Despres was M. St. Germain, who, while professing to believe
that mercury does render some indefinite service in syphilis,
declares at the same time that he considers it as useless against
chancre, that he has a "certain tendency not to administer it in
secondary syphilis," and that he always combats tertiary symp-
toms by iodide of potassium.

It appears, therefore, that not much new light has yet been
thrown on this important subject by the debate. The society
is waiting to hear the opinion of M. Diday, pupil of Ricord,
whose voice would naturally have much influence.

More original views were presented in a recent discussion at
Lyons, on the same subject, /where several of the members main-
tained that it was unnecessary to spend much time or thought
upon the cure of patients who had fallen a prey to the disease in
consequence of misconduct, and that especially such patients
should never receive the benefit of gratuitous treatment.

Vesico-Vaginal Fistula Treated by the American Method.

M. Courty, Professor at Montpellier, publishes an account
of six cases of vesico-vaginal fistula, successfully operated by the
"American method." The Bulletin of Therapeutics publishes
the details of two that presented unusual difficulties. In one,
the fistula, five centimetres long, dated from four years, the

Letters to the Medical Record 15

urethra was obliterated, and vagino-pubic adhesions existed.
There was also a hernia of the bladder. Owing to the adhesions,
the operation was exceedingly difficult, the haemorrhage abun-
dant, and the lips of the wound did not completely close. After
a second operation, however, performed upon the gaping part of
the suture, adhesion was effected, and a radical cure completed.
The treatment lasted four months. In the second case, the pa-
tient, a woman 28 years old, had already been operated upon
unsuccessfully, and a cicatricial tissue, hard and thick, bordered
the edges of the fistula, which was eight millimetres long. In
this case also, two operations were necessary.

M. Courty only revives the borders of the fistula, at the
expense of the vaginal mucous membrane, carefully avoiding
the vesical. For the deep sutures he uses Startin's needles, and
for the superficial, Sims'. He leaves a sound constantly in the
urethra, and by means of a canula pushed to the bottom of the
vagina, has the cavity washed out twice a day with a lotion to
prevent suppuration. The wires are withdrawn between the
fifth and tenth days.

Mistake between an Ovarian and Renal Cyst.

The Gazette Hehdomadaire quotes a case of a mistake made
between an ovarian and renal cyst by the distinguished Dr.
Wells of London. A woman of 43 years presented herself at his
hospital, to be treated for an abdominal tumor, that two ex-
perienced physicians had already pronounced to be an ovarian
cyst. They had refused to operate, however, because a loop of
intestine was recognized as passing in front of the tumor. On
the 4th of August, when Mr. Wells first saw the patient, the tumor
had risen to the epigastrium, and the patient seemed threatened
with suffocation. He punctured the cyst to her immediate relief,
and the tumor and dull percussion sound entirely disappeared.
Two months later, the woman returned to the hospital, with
the tumor again filling all the abdomen. On the left of the
umbilicus was recognized a hard band, which was supposed by
some to be a loop of intestine, by others the Fallopian tube.
The menstruation was regular; the urine contained mucus and
epithelium, but no albumen. The abdomen was largely opened
in the median line. The incision of the peritoneum revealed
passing in front of the cyst, the transverse and descending colon,

1 6 Mary Putnam Jacobi

intimately adhering to the abdominal walls and also to the cyst;
15 pints of gray purulent liquid were withdrawn from the cavity.
The destruction of the adhesions revealed a second cyst, which
yielded two pints of clear liquid. Finally, since it was impossible
to destroy the deep adhesions, the cyst was left in place and the
wound closed. The patient succumbed the next morning. At
the autopsy the following state of things was manifest: Four
pints of sanguinolent sertun and of coagula were effused in the
peritoneum. The uterus and ovaries were perfectly healthy. The
0ght kidney was hypertrophied, and much softened, a calculus
of 40 centigrammes was found in the calix. The left kidney was
converted into a cyst more voluminous than the head of a foetus,
containing a single cavity divided by bridles, and whose walls
were formed by the renal capsule. The parenchyma had
completely degenerated and atrophied.

A precisely analogous case occurred here the other day, at
La Pitie, in the ward of M. Belrier. The patient was 48 years
old, and feeble, and on this account it was decided that ovario-
tomy was unadvisable, although an ovarian cyst was diagnosed
without any hesitation. Tapping was followed by the complete
collapse of the tumor, which, however, resumed its original
dimensions in two or three weeks. At the time of the patient's
death, two or three weeks after the operation, the cyst contained
several quarts of liquid, and occupied all of one side of the abdo-
men, from the iliac fossa to the hypochondrium. At the post-
mortem, this tumor was found to be an enormous cyst of the
kidney, whose entire parenchyma was destroyed, and only the
capsule left, lined by a serous membrane of new formation, but
of sufficient secreting power to reproduce the entire volume of
liquid in the course of two or three weeks.

Mr. Wells has profited by his mistake to make a more careful
study of the points of diagnosis between renal and ovarian cysts,
and has published some most valuable reflections. The diag-
nosis, he says, should be based on the following circumstances:

I St. Whenever a bridle of intestine is recognized as passing in
front of the cyst, it is almost certainly renal, since the ovarian cysts
push the entire intestinal mass of it against the vertebral column.

2nd. The ascending colon would be found on the internal
side of the right kidney ; the left is crossed from above downwards
by the descending.

Letters to the Medical Record 17

3rd. The urine, which should be subjected to a microscopic
examination, nearly always contains mucus, epithelium, pus or
albumen, in cases of renal tumors, whilst the menstruation is
not disturbed as it is in ovarian disease. (This latter circum-
stance evidently cannot be relied upon in the numerous instances
where the tumor is developed after the menopause.)

4th. The bridle, on percussion, is found to be contracted
like a cord, and is mobile.

5th. In the case of ovarian cysts, the liquid often escapes
by the Fallopian tube, after adhesions have been contracted,
while in renal cysts the way of escape is by the ureter and bladder.

6th. Renal tumors appear first in the hypochondria, and
develop downwards; ovarian in the iliac fossa, and pass upwards.

Mr. Wells concludes that henceforth no one need make a
mistake between the two diseases.

Cancer of the Kidney, etc.

While speaking aboutrenal tumors, I must mention a highly
interesting case at present in the service of M. Herard, at Lari-
baissi^re, where an inverse mistake in the diagnosis was induced
by the ambiguity of the symptoms. The subject, a woman of
about 38, entered the ward the 31st of March, presenting an
abdominal timior that occupied the left iliac fossa, and extended
in front to the umbilicus, and behind to the spine. A smaller
tumor was situated in a precisely similar manner at the right
side. The patient had begun to suffer five months before her
entrance, with severe pains in the renal and dorsal regions, which
were presently followed by the development of the left tumor,
which rapidly increased to its present size. The disease had
attacked the right side about a month ago. The anterior border
of the tumor could be felt distinctly in front; behind the limits
were more vague. Clear percussion sound was obtained between
the dulness of the tumor, and that proper to the spleen. Also,
the mass did not continue into the inguinal region, or pass the
median line, so that the idea of an ovarian disease was set aside.
The position at the left of the principal mass put the liver out
of the question, and the appearance of a similar tumor in the
right renal region indicated that a symmetrical organ was in-
vaded. Everything, therefore, led to the belief that the disease
occupied the kidney, a belief (as I hasten to say) that so far

1 8 Mary Putnam Jacobi

nothing has contradicted. But the tumor presented quite dis-
tinct fluctuation. The complexion of the patient, though pale
and chalky, had no tint of special cachexia, and the diagnosis of
renal dropsy (hydronephrose) was pronounced. A surgeon in con-
sultation agreed in this opinion, and tapped the tumor. There
issued, neither urine nor serous fluid, but a small quantity of juice,
which, both to the naked eye and the microscope, was evidently
cancerous. The greater part of the tumor was, after all, solid.
The patient is still alive, and her condition is liable to great
variations. For a long time after her entrance to the hospital
she suffered almost continually from pain, which, finally, seemed
to be relieved by subcutaneous injections of morphine. A week
ago she was a great deal better, sat up, embroidered, felt quite
at her ease, but a relapse has just occurred, and she is now about
in the same state as when she entered. During the first weeks
the tumor seemed to increase, but for the last six weeks it has
been quite stationary. Since the tapping (which did not ma-
terially diminish the size of the tumor) , the sensation of fluctua-
tion has disappeared, and now the surface of the mass is more
uneven, though never hard, or distinctly bosselated. The cancer
is evidently an encephaloma.

Contractibility of Muscular Fibre.

Before closing my chronicle, I must tell you of some singular
experiments that have just been made by M. Rouget upon the
contractibility of muscular fibre. M. Rouget commenced his
researches on the subject, by the study of the style of the vor-
ticellus, where the muscle consists of a single fibre. This is
elongated during life, but under the influence of excitants, or
after the death of the animal, the spiral returns brusquely on
itself, and is shortened four-fifths, being transformed into a
spiral spring, pressed closely together. Experimenting subse-
quently upon living animals, Rouget found that everything that
interfered with the nutrition of the muscles, made them contract.
If the main artery of a limb were tied, if galvanic excitement
was continued incessantly, if the muscles were subjected to a
continually increasing heat or to cold, the result was always the
same, they contracted. When the contractions were too frequent,
the myographion showed that the transverse lines repeatedly
approached each other, could no longer separate, but remained,

Letters to the Medical Record 19

as it were, agglutinated. Rouget declares that the primitive
muscular fibre is constituted by an elastic fibre twisted in a spiral,
and that the transverse lines mark the curves of this spiral, and
not the segmentations of a straight bundle of fibrillar elements,
as usually maintained. The state of repose, the normal state
of this spiral, is that of the approximation of its rings, which
appears to the eye as the contraction of the muscle. The length-
ening is the really active process, and can only occur during the
vigor of life. The cadaveric rigidity of muscles is precisely the
same phenomenon as that occurring when their vitality has been
exhausted by heat or cold, or starved out by lack of food. When
a muscular fibre shortens, it does so in virtue of its own elasticity,
which triumphs over the vital force developed in the act of nutri-
tion. This or any other force that excites motion in the muscles,
at the moment that it ceases to act, is transformed into heat,
and hence the rise of temperature observed in muscles entering
into a state of contraction.

Muscles do not contract in successive undulations or shocks,
except at the beginning of the action of an external excitant, or
when they are exhausted by fatigue. Contracted muscles seen
under a microscope, are found to be perfectly motionless. When
they contract by the will, there are no undulations even at the
beginning of the period.

The influence of this theory, which reverses the passive and
active sides of muscular movement, upon tetanus, chorea, and
all diseases of muscular activity, is easily perceived. But M.
Rouget as yet attempts no pathological applications.

Un joli mot, as the French say, in conclusion. You are
familiar with the name of Charcot, I suppose, and of his intimacy
with the distinguished surgeon, Vulpian. The two have so often
published together, that their names are inextricably associated
to the public ear. The other day a friend of Charcot's observed :

"Charcot has been made happy this morning. He is the
father of a son."

"What," exclaimed a bystander, "Charcot and Vulpian?"
But it was explained that this time it was Charcot, tout seul.

The Origin of Modern Anaesthesia.

I have not yet finished, for I must mention the compliment
paid by the Gazette Hebdomadaire to the Medical Record, as

20 Mary Putnam Jacobi

"the most serious medical journal in the United States." When
the Record ascribes the first (chronological) honor of chloroform
to Dr. Wells, the Gazette thinks that the question is settled.

P. C. M.

Paris, August 19, 1867.

To the Editor of the Medical Record.

Sir — The School of Medicine held its annual closing cere-
monies on the 14th. M. Behier pronounced an eloquent eulogy
upon Rostan. On the 17th the amphitheatre of the Ecole was
again filled to celebrate the opening of the International Medical
Congress, where seven hundred physicians from all parts of the
world, representing nearly all the celebrated physicians living,
had gathered together.

The International Medical Congress.

The hemicircle was draped with the flags of all nations. The
eagle of Prussia floated in the midst of the colors ot France, and
the Turkish crescent fraternised with the banner of England.
M. Bouillaud presided, supported on the right by M. Gavarret,
on the left by M. Tardieu, and pronounced an eloquent address,
whose feeling was responded to by every member of the great
assembly. When the illustrious professor said, "I cannot con-
template this scene without being profoundly moved; I feel my
feeble powers fail to express the just sentiment of the occasion,"
all the audience replied by bravos the most sympathetic; and
when the orator concluded, "Let us rise to salute these entwined
flags, and then unite our hands as they are united, in sign of
complete and cordial fraternization," the enthusiasm was at its
height, and the amphitheatre resounded with a thunder of ap-
plause.

But alas ! having been at its height, it was all the more liable
to fall. The day was very hot, and the old amphitheatre was
constructed for other purposes than those of ventilation. The
question of the day was tuberculization ; and after the reading of
the first memoir, the audience began to reflect, to calculate that
many more were to follow, that they were "in" for three or four
hours at least. People grew restless and anxious. Presently

Letters to the Medical Record 21

every one was electrified with a voice, whose timbre, entirely
exotic, pierced right through the decorum, of the assembly,

"M. President, is it permitted to ask a question?"

"Certainly; speak."

"I am a stranger; I am a physician from Holland, and as a
Hollander I have been invited to assist at the International
Congress, but I find I have made some mistake; for in my
opinion this is no congress, but a class, a school-room, where
some doctors have come together to admire each other, and hold
themselves up for admiration."

Literally, that is what the honest Dutchman said. He
spoke with all the traditional phlegm of his race; he scanned
each word, and the ironical syllables fell into the midst of the
"band of brothers" like so many bomb-shells. Of course there
was confusion, and calls to order ; then, finally, the reading of the
papers on tuberculization was resumed.

The other questions that will occupy the Congress are as
follows :

Second Session. — Continuation of the discussion on tubercu-
losis. Discussion on the influence of climates, races, and
different social conditions upon menstruation in diverse countries.

Third Session. — On the constitutional accidents which occa-
sion death after surgical operations.

Fourth Session. — Is it possible to propose to different govern-
ments efficacious measures to restrain the propagation of venereal
diseases?

Fifth Session. — On the acclimatation of the races of Europe
in warm countries.

Sixth Session. — On the influence of alimentation upon the
production of certain diseases in different countries.

(The memoirs announced upon this question all relate to
pellagra.)

And in the same seance will be developed some considerations
upon entozoa.

This programme promises well, some of the topics being of
extreme interest and importance, and only capable of being
studied in the light of the experience of physicians of many
nationalities. All the medical world that is not at the congress
has gone into the country, whither we will follow them, and col-
lect some gleanings from the rich harvest of the provincial socie-

22 Mary Putnam Jacobi

ties, which in intelligence and learning are not inferior to those
of Paris.

The Contagion of Cholera.

The Imperial Society of Medicine at Lyons, in the sdance of
the 15th of July, listened to a dissertation by M. Rodet, upon
the capital question of the contagion of the cholera. M. Rodet,
who occupies a middle ground between the non-contagionists
and the contagionists, commenced by citing a certain number of
facts that had been adduced by each party in proof of its theory.
On the side of the first, four. In 1835, the vessel Ville de Mar-
seille was stationed two or three miles from Toulon, where the
cholera was then raging, and the crew had frequent intercourse
with the infected city, yet not a person took the disease. In 183 1,
among a hundred nurses and attendants upon cholera patients
in the hospital at Cairo, not a single person took the cholera;
eighty nurses in the hospital of Monsourah have enjoyed the same
immunity; and among sixty at the hospital at Damiette, only
one took the cholera. Again, at the Hospital of the Dey at
Algiers, the immunity of the persons attached to the cholera
wards was so great in 1865, that one might have supposed them
to be asylums of refuge. Finally, in the Military Hospital of
Constantinople, 1,488 cholera patients were received from the
27th of January, 1855, to the 31st January, 1856, of whom 658
died. Their clothes and linen were washed by the hospital
attendants; the privies exhaled from time to time fetid emana-
tions, which spread throughout the hospital, and even beyond
its precincts; yet in spite of so many conditions favorable to
contagion, the disease was not communicated to any other
patient, or to any of the persons attached to the wards.

It is noticeable, however, in connection with the first case
cited, at Toulon, that although the crew of the Ville de Marseille
was so remarkably spared, twelve physicians succumbed to the
epidemic. In 1865, there perished in the same city six physi-
cians, two apothecaries, ten nurses at the marine, and five at the
military hospital, in all twenty-three persons connected with the
care of the cholera patients.

In these cases, however, the non-contagionists may still urge,
that the victims were at the same time exposed to epidemic
influence, so that it is impossible to tell what share contagion

Letters to the Medical Record 23

had in the infliction of the disease. This argument does not
hold in regard to seven other cases quoted by M. Rodet, occur-
ring during various epidemics, and one related in detail by M.
Petiteau, that he observed last September. In all these cases
the infection seemed to be directly transmitted by persons going
from an infected to a healthy locality, was first communicated
to persons with whom they came directly into contact, and
thence from individual to individual, over a certain radius, after
which the morbid influence seemed to be extinguished. In only
one case was a wide-spread epidemic excited. In five of these
eight cases the disease was imported by people who had visited
the infected locality, merely during a few hours or days, and were
attacked shortly after their return home, communicating the
disease to those who nursed them. In M. Petiteau's case the
attendants on the patient escaped, but after his death a drunken
comrade, who persisted in passing all night by his corpse, em-
bracing it, and committmg a thousand extravagances, was
speedily smitten. Twelve cases followed this infection, of which
six died. In the cases cited by Rodet, for the first, only the son
and husband of the original patient died, while she recovered,
and the disease went no further. In the second instance, only
the mother of the patient was carried off, while he recovered. In
the third, fourteen persons perished out of a population of 130
inhabitants. In the fourth, there were thirty-one deaths in
thirty-four days. The other three instances of infection men-
tioned by Rodet were occasioned by the flight of persons from
places where they had lived, for some time during the prevalence
of the epidemic, into healthy localities. In the first case, a gen-
eral epidemic was lighted up. In the second, all the members of
a family living in different houses were successively attacked.
In the third, twenty-seven persons were attacked, of whom
twelve succumbed.

M. Rodet, although attaching full importance to these facts,
as proof of the communicability of cholera by direct contagion,
is careful to point out that such influence cannot explain all the
bizarre phenomena of epidemics, and that it is necessary to admit,
over and above the focus of infection, a general cause which hov-
ers over all the individuals placed in this focus, an epidemic
cause, a qiiid divinuni or ignotum as has been so often repeated.

The Medical Gazette of Algiers reviews a recent work by

24 Mary Putnam Jacobi

M. Jules Girette, where this question of the epidemic influence
is treated on the largest scale. This writer, by the very title
of his work, Civilization and the Cholera, betrays that his views
are liable to be all rather biassed by the idea that belief in
contagion must tend to barbarize nations, and hence ought to be
discountenanced on moral grounds. It is rather unfortunate
that this initial bias should be so perceptible, for it somewhat
tends to shake the reader's confidence in the complete impar-
tiality of the author's statements. Yet various circtmistances
pointed out, concerning the march of the epidemic of 1865, along
the shores of the Mediterranean, seem certainly difficult to
reconcile with the theory of the perfect efficacy of quarantine.
"Greece and Sicily isolated themselves completely, and escaped
the cholera. But so also did Corsica, which continued to com-
municate freely with the infected cities of Nice and Livourne,
and only subjected vessels coming from Marseilles, where the
epidemic was at its height, to a quarantine of three days. Salon-
ica and Volo, unexpectedly exposed to the contagion, after a
prolonged quarantine, nevertheless escaped. Neither Sarn-
soum, nor Catourn, nor Dourgas, nor Varma were attacked by
the cholera, although they were constantly visited by emigrant
vessels. It scarcely touched Trebisond, traversed by hosts of
fugitives en route for Persia. Yet all these ports had no other
defence than a quarantine of from three to five days. At Malta,
Bey rout, Dardanelles, and Odessa, the epidemic was communi-
cated to the city by the lazaretto that professed to protect it.
At Constantinople, a Turkish frigate evaded the quarantine,
and imported the disease. Majorca, surrounded by a cordon
sanitaire, attributed the cholera by which it was decimated, to
some secret fraudulent importation, since no other cause could
be discovered. The same with Alicant. At Enos the epidemic
raged, and could be explained by no suspected communication.
Trieste, spared up to the 28th of September, and believing itself
secure behind a model lazaretto, awoke to find the cholera within
its walls. Southampton, freely open to arrivals from Alexandria,
did not register its first death from cholera until the 25th of
September, nearly at the same time as Trieste, and two months
after Marseilles."

M. Girette, however, takes great pains to trace the march
of the epidemic of 1865, from its cradle, among the hordes of pil-

Letters to the Medical Record 25

grims to Egypt. M. Jobert, however, sanitary physician on
board the Arethusa, who reviews the book, lays much more stress
than the author upon the fact that some new and peculiar atmos-
pheric conditions, or epidemic capacity, must have prevailed at
Eg^^pt during that year, since every year the pilgrims were in
the habit of having the cholera at Hedjaz, but it was not com-
municated beyond their own camp. M. Jobert quotes with
especial emphasis the description given from personal observation
by M. Girette, of the state of things at the temple of Withoba,
at Punderpoor, where men and women were crowded together
by thousands, in a narrow court, awaiting their turn to enter
the temple. Inside the little stone temple the same, and worse;
the emanations from the bodies of the worshippers condensed
upon the statue of the god, and the moisture was regarded as a
miraculous sweat! The resident physician at Punderpoor be-
lieves that the first origin of the cholera is probably at this cele-
brated shrine.

To return for a moment to M. Rodet. He speaks hopefully
of the good effects of the treatment suggested by Dr. Burg, and
in 1865 experimented by M. Lisle, physician at the Insane Asylum
at Marseilles. Upon the appearance of the epidemic in the
asylum, M. Lisle had at first endeavored to combat its ravages
by the ordinary method of diffusible stimulants. He lost twelve
patients out of fourteen, a number much greater than the ordin-
ary average, and whose excess is to be attributed to the much
feebler resistance to the disease offered by the insane. Finally
the servant of M. Lisle was attacked; he employed the same
treatment, and with equal lack of success, for at the end of
twenty -four hours all hope seemed to be lost. In this extremity
he resolved to try Dr. Burg's prescription, and considerably to his
surprise the woman recovered. He then applied the same treat-
ment to the remaining patients in the wards, and the results
surpassed his expectations. Among twenty-six men he ob-
tained twenty-one recoveries, and among six women (including
his servant), four; in all, twenty-five cures among thirty-two
cases.

The following is the formula for the remedy that obtained
such unlooked-for success :

Dissolve five per cent, of sulphate of copper in 150 grammes
(about five ounces) of distilled water; and add to this 150

26 Mary Putnam Jacob!

grammes of sugared water, together with lo drops of Sydenham's
laudanum.

A Case of Osteomalacia.

At the Society of Medical Sciences at Lyons, was recently
presented by M, Verard, a most interesting case of osteomalacia.
The patient, as usual, a woman, was thirty years old, and had
been the victim of the disease for ten years at the time of her
death, which occurred in an attempt at child-birth. I have been
unable to find the details of the case as related by M. Verard,
having only at hand a subsequent report upon the case, made
by Dr. Berne, surgeon at La Charite at Lyons.

In this report is only noticed, that the commencement of
the disease had been characterized by sharp pains, which had
been supposed to be rheumatismal ; that the pregnancy had, as
usual, greatly accelerated the march of the disease; that the
diseased bones presented were all highly porous; that in the
spongy tissue, the osseous trabeculas had become rare, or had dis-
appeared; the medullary spaces had united together, and in the
hollow bones contributed to enlarge the medullary canal; that
even in the cortical compact substance, the vascular canals were
enlarged, and formed areolae, which uniting transformed it into
a spongy tissue of large network; which indeed was so general
that the compact tissue had almost disappeared, and there only
remained the superficial layer, which, moreover, was infiltered
by a yellow, fatty, medullary substance; that, besides, in the
parts of the osseous system which were the most altered, were
discovered numerous cells resembling pus globules.

This last fact seems to confirm the opinion of Virchow, who
ascribes osteomalacia to a parenchymatous inflammation, the
immediate consequences of which are only an interstitial exuda-
tion, but the remote result is the destruction of the osseous
tissue.

A chemical analysis of the bones was made, principally with
a view of searching for lactic acid, and thus indirectly testing
the theory' that ascribes the resorption of the lime salts to the
presence of this agent. It was impossible to find lactic acid in
the free state, for at the time the analysis was made, the bones
had already submitted to maceration for several days in water

» Of MM. Marchand, O. Schmidt, and Otto Weber.

Letters to the Medical Record 27

saturated with marine salt, and the acid, if present, would neces-
sarily be dissolved. But some lactates might still be left. To
settle the question, the ashes of the calcined bones were treated
with water, thus losing a considerable portion of their weight
(0.42 gr. out of 0.99 gr. for the spongy substance, and 0.23 gr.
out of 1.73 gr. for the compact). The filtrated substances, pre-
cipitated with nitrate of silver, gave 0.20 chloride of sodium in
the first case, and o.io in the second. Remained 0.22 and 0.13
of residue, in which, if anywhere, the lactates were contained.
In this residue, dissolved in distilled water, the presence of an
organic acid was presently proved by the addition of a few drops
of nitric acid, then lime-water, which formed a precipitate, prov-
ing that the nitric acid had found material to convert into oxalic
acid, which produced an oxalate with the lime. Further exam-
ination showed that the solution did not precipitate with bar)rta-
water, had no action upon lime-water until it had been treated
with nitric acid, and gave a white precipitate with concentrated
acetate of zinc, whence the presence of lactic acid was conclu-
sively proved.

The usual disproportion between the organic and inorganic
materials of the bones was also shown by the analysis. The
proportion in 100 of the inorganic matter instead of being 64,
the normal figure for compact bone, was 41, and in the spongy
substance not more than 18.

The proportion between the carbonates and phosphates re-
mained the same, the former being one-tenth the weight of the
latter.

M. Verard very justly regretted that no experiments had
been made to ascertain whether, in spite of the narrowness of
the basin, the head of a foetus could not have been made to pass,
in virtue of the softness of the bones. The antero-posterior
diameter of the inferior strait only measured from a centimetre
and a half to two centimetres; but the bones were so soft, that
the first placed in the pelvic cavity easily forced a place for itself.
Dr. Berne thought that in a similar case, at a moment of ac-
couchement, before the obstetrician should address himself to
the cesarean operation, he should seriously consider whether the
pelvic basin were not susceptible of enlargement by dint of
pressure. In the case in question, I am unfortunately unable to
tell what was actually done.

28 Mary Putnam Jacobi

The Function of the Vascular Glands.

At a recent seance of the Academy of Medicine in Belgium,
Dr. Foisson read a paper, propounding a theory on the function
of the vascular glands, that seems to mc much the most ingenious
and complete of any that has ever been advanced concerning
them. This theory carries out the suggestion made by Brous-
sais, who assigned to the spleen the function of deviating the
blood from the stomach; so the thymus and thyroid, a similar
role for the respiratory organs. This idea, however, being based
upon no serious proof, passed unperceived. But M. Foisson has
greatly enlarged and strengthened it in his essay, of which I shall
endeavor to give you an idea.

The general theory of derivation is the following: All organs
submitted to alternations of action and repose, require a greater
amount of blood during the first than the second period. The
variations thus necessitated in their circulation, are effected by
an agency independent of the general circulation, namely, the
appropriate vascular glands, that act by driving the blood away
from the organs when they have no need of it.

The only organs in adult life, engaged intermittently in
active functions, are the muscles, stomach, brain, and uterus.

The muscles, when acting separately, mutually derive the
blood from one another, and when they act all together, the
heart quickens its action, and sends the excess of blood required.
Their variations, therefore, depend directly on the general circu-
lation, and they have no need of special apparatus.

But the stomach is essentially intermittent in its activity.
The secretion of gastric juice evidently demands a large amount
of blood, to judge from the size of the arteries distributed to its
walls. During the intervals of digestion, these arteries are tor-
tuous, and comparatively little blood passes through them.
The blood from the coeliac axis being mainly distributed by the
splenic artery to the spleen, the tortuousness of this splenic
artery may be supposed to be unfolded at an opposite time from
that in which the gastric arteries grow straight.

The thyroid gland is the derivative reservoir for the blood
going to the brain. This blood arrives at the thjToid from the
superior thyroidien given off from the internal carotid — and the
inferior thyroidien, that springs from the subclavian close by the
origin of the vertebral, so that by a double route the circulation

Letters to the Medical Record 29

of the thyroid can affect that of the encephalon. In virtue of
that same connection, between the thyroid and the brain, do
persons affected with goitre so often become cretins; the exag-
gerated development of the thyroid interferes with the nutrition
to the brain, and the more important organ is actually starved
out by the fraud of the less, which seizes its supplies en route.
Finally, for the uterus, the mammary glands perform the office
of derivation, and, after parturition, when the uterus must
retract, and has no further need of the expensive nourishment
upon which it has subsisted during pregnancy, the epigastric
arteries, prepared for the task by the development they have
experienced during the last months of this period, intercept the
supply of blood going to the uterus, and convey it to the glands,
by means of their anastomoses with the mammary arteries.
Among animals in whom the mammary glands are abdominal,
the epigastric artery supplies them directly. To this extremely
suggestive interpretation of the well-known facts of the case, one
difficulty may be addressed. If the extra nutrition of the uterus
and mammary glands is carried on at alternate periods, how
does it happen that the glands increase during pregnancy ? This
fact, however, is really provided for by the theory which admits
that the satellite organs do increase coincidently with their
principals, if only for the sake of being at hand, and in good
condition, to receive the brunt of their circulation when the
functions of the principal organ is intermittent; but that in
addition to this parallelism of development, comes the alterna-
tive, or contrast, at the moment when the principal organ sub-
sides into inactivity, and the satellite starts into full activity.

For explanation of the office of the thymus gland and supra-
renal capsules, the theory is identical, but applied as it were in
an inverted fashion as respects chronological order. The lungs
and kidneys do not function at alP during foetal life, and hence
have need of only so much nutritive fluid as is required for their
growth. But as they begin to act at the very moment of birth,
the new supplies necessary for the maintenance of their functions
must be stored up close at hand, ready to be turned into their
future channels. For this purpose the thymus gland and supra-
renal capsules are contrived. The blood during foetal life is

' This is the remark of the author. But I believe it is not strictly correct
for the kidneys, since the bladder is found to contain urine before birth.

30 Mary Putnam Jacobi

directed towards them, as it were next door, but at the moment
of birth the current is turned into the neighboring arteries, and
from that moment the foetal organs begin to waste and gradually
disappear.

The thyroid gland also, though in action throughout life,
is much required during infancy, since the brain at that period,
as far as regards its intellectual functions, is in a quiescent or at
least passive state, consequently the thyroid gland of children is
proportionately much larger than in adults.

M. Foisson refers to the characteristics common to the
structure of all the vascular glands, as tending to confirm his
theory. Huschke and Kolliker agree in recognizing in all these
organs the existence of:

1. A foundation system of trabeculas, serving for a support
to the vessels.

2. Vesicular cavities occupying the interstices left between
the trabeculae.

3. The presence in the cavities of a liquid charged with glo-
bules, and the absence of any efferent canal. Nothing in this
structure suggests the idea of a secretion appropriated to the
perfectionment of the blood or lymph, while it is on the contrary
marvellously adapted for the purposes of derivation.

The entire theory is resumed in the following propositions :

1 . All the organs of the economy consume during the periods
of their activity an amount of blood more considerable than that
required in repose.

2. In the normal state, the heart sends at each moment the
same quantity of blood in every branch of the arterial tree.

3. The blood which arrives at organs in excess during their
period of repose, is received by special organs called derivators.

4. The function of derivation may be performed without
the intervention of an organ exclusively devoted to the task, as
in the case of the mammary glands.

5. Every organ whose function is intermittent, possesses
an apparatus for derivation.

6. Derivation is not only arterial, but sometimes venous,
as when the spleen receives the trop plein from the portal vein, or
the thyroid, during muscular exertion, from the engorged jugulars.

7. Derivation is a complementary function of the circula-
tion, and necessary to a regular distribution of the materials of

Letters to the Medical Record 31

nutrition and secretion. At the same time it is not absolutely
essential to life, so that in the lower animals any of the vascular
glands may be extirpated with impunity.

8. Derivation is explained by the following law of physics:
When a pipe traversed by a fluid is divided into two branches,
that of the two in which the current is the most rapid receives
a ^eater quantity of liquid than the other.

This theory is so perfectly captivating to me, that as yet I
have not been able to imagine any serious objection to its sound-
ness. Perhaps you or your readers may be more critical, and I
submit it to your judgment.

Union by First Intention after Lithotomy.

Professor Bouisson, of Montpellier, is at present writing a
series of articles in the Montpellier Medicale, upon union of the
wound by first intention after the operation of lithotomy. The
Professor not merely believes this to be possible, and in his first
paper adduces four cases in proof of his assertion, but engages
to show how this very desirable result can be secured. Of these
four cases, the first was that of a young man who had been treated
for some time with elastic bougies, in the hope of sufficiently
dilating the urethra to admit of the operation of lithotrity. All
at once, however, the patient became unquiet and irritable; an
obstinate spasmodic condition of the canal joined itself to the
organic retraction, and forced the surgeon to abandon all hope
of crushing the calculus, and an operation for lithotomy was
decided upon. Owing to the presumed smallness of the stone,
the median incision was selected. The operation was performed
on the 1 6th of December, and encountered no serious difficulties.
An incision of three centimetres practised on the median line of
the perineum easily attained the urethra. After division of the
cutaneous and cellular layers, the membranous portion being
directly divided, the length of the left edge of the catheter which
had been introduced in the urinary canal to serve as a guide, a
lithotome was introduced, the catheter withdrawn, the finger,
gorget, and forceps successively introduced into the bladder, and
the calculus seized and extracted.

The calculus was spheroidal, with irregular surface, so com-
pact and hard that the operation of lithotrity would have been
very difficult. A vesical injection terminated the operation,

32 Mary Putnam Jacobi

which had been performed with the assistance of chloroform.
The knees of the patient were then drawn together, and main-
tained in an elevated position by a cushion placed underneath;
a calming and diffusible draught was administered; the day
passed without fever or vesical pain; the patient vomited twice;
in the evening a little urine escaped by the natural passage.
The next day reddish urine was passed naturally, also a ver>'
small amount escaped at the wound, whose appearance was
good. During the two following days also the local and general
phenomena were satisfactory; the urine nearly entirely passed
by the urethra. The wound closed without suppuration, and by
the eighth day was completely cicatrized by first intention. The
cure was permanent.

In the second operation performed by M. Bouisson, the
patient was sixty-four years old, and the bladder contained six
calculi and was completely paralyzed. After the operation,
whose details I will not repeat, the persistent retention of urine,
which did not even escape by the wound, rendered it necessary to
leave a sound permanently in the bladder, for the accumulation
caus-ed much pain and suffering to the patient. By this means
also the urine was completely turned away from the wound, a
circumstance which undoubtedly favored its union, which was
effected in six days, by first intention, without any trace of in-
flammation or infiltration. In this case also the median incision
had been practised. The third, the same form of the operation.
The subject was sixteen years old; the calculus, though hard and
voluminous, was ovoid, and presented itself to the forceps by its
most favorable diameter, so that it was extracted without dif-
ficulty. After the operation, the adduction of the thighs was
secured by means of an apparatus, so that the lips of the wound
were brought in contact, and the dorsal decubitus strictly en-
joined. The first day only the urine escaped by the wound; after
that the patient was able to urinate voluntarily. Even after
the subsidence of the swelling around the lips of the wound,
which might at first have opposed the escape of the urine, that
liquid continued to traverse the natural passages, and owing to
this fortunate circumstance the wound was cicatrized by the
sixth day. Neither infiltration, nor ecchymosis, nor suppuration
supervened, and the cicatrix remained perfectly solid. The
fourth operation, with the medio-lateral incision, was performed

Letters to the Medical Record 33

on a child of six years old, who had suffered from painful micturi-
tion from the age of two years. In this case the first sounding
had failed to discover the calculus, and although that was dis-
tinctly perceived at the second examination, it seemed again to
disappear at the moment of the operation. Nevertheless, M.
Bouisson made the incision. The posterior radius of the pros-
tate gland seemed so short, in consequence of the flattening of
this organ, that, having practised the median section of the skin
as far as the urethra, M. Bouisson judged it prudent to incline
the lithotome in the direction of the oblique radius of the prostate,
in order to avoid the rectum, and to limit this oblique section to
the gland, so that the incision represented a broken line whose
first part was straight, and the second oblique. This opening,
more than sufficient for the extraction of the calculus, gave issue
to a certain quantity of urine, which carried the stone along with
it into the very grasp of the forceps. The calculus was the
volume and shape of an olive; mammillated, reddish-yellow, and
composed of uric acid. The whole operation only occupied three
minutes from the moment of the incision to the extraction of the
stone.

In consequence of the inclination of the lithotome, a branch
of the perineal artery had been divided, giving rise to consider-
able haemorrhage, an accident that had been entirely avoided in
the other operations. The haemorrhage was arrested by torsion
of the vessel, but returned some hours after the operation, to be
finally vanquished by compression and the application of ice.
This was the only notable effect of the operation. The urine
escaped by the wound during the evening and in the night; but
after the first day the passage of urine ceased to be continual,
and came under the influence of vesical contraction. Towards
the end of this day a part of the urine passed by the urethra, and
from the fourth day no more escaped from the wound, which
united without suppuration, and without the occurrence of
either sanguine or urinary infiltration. By the eighth day the
cicatrization was complete.

All these cures were obtained by the perineal operation.
M. Bouisson thinks that such happy results could rarely be
achieved when the hypogastric incision was practised. In suc-
ceeding papers he hopes to develop further . views suggested by
the interesting observations of which I have related the summary.

34 Mary Putnam Jacob!

New Apparatus for Irrigation of the Eye.

Dr. Amable Cade, of Saint Andeal, also makes a communica-
tion to the Montpellier Medicale, concerning a new apparatus
devised by himself for securing continual irrigation of the eye
after the operation for cataract. This is composed :

1. Of a hemispherical reservoir, of a capacity of nearly
a quart, with an opening at the top, and capable of being sus-
pended over the head of the patient.

2. Two supra-ocular recipients, of lozenge shape, each
furnished with two little handles, destined either to fix the
apparatus before the eyes by the aid of a circular band, or to
keep in place the two recipients when both eyes have been operat-
ed the same day. Their posterior side is made of gold-beater's
skin, which ought to be placed in immediate contact with the
closed eyelids.

3. Two tubes, communicating between the reservoir and
the recipients. These tubes are furnished with screw joints,
which permit the suppression of one of the recipients when only
one eye is operated.

4. Little pieces of sponge loosely introduced in the com-
municating tubes, to prevent the passage of the water, except
drop by drop, every second in ordinary cases. These sponges
may be removed in case of imminent danger from violent inflam-
mation, when a rapid current of cold water is needed.

5. Two discharging tubes, a yard and a half in length,
destined to conduct the irrigating fluid from the recipients to a
vase placed by the bedside.

By means of this apparatus. Dr. Cade has already performed
eight operations for cataract with the most complete success,
in some cases warding off a commencing phlegmonous inflamma-
tion, that threatened to become a terrible complication.

P. C. M.

The International Medical Congress.

Paris, Sept. 9.
To the Editor of the Medical Record.

Sir — Now that the International Medical Congress has come
to an end, it may not be inappropriate to review its proceedings,
and endeavor to form an estimate of its results.

This task cannot fail to disappoint. It is acknowledged on

Letters to the Medical Record 35

all hands that the Congress was ill-organized, the programme
"arranged without sufficient tact, and the legitimate aims of the
discussions almost entirely lost sight of. Evidently the great
advantage to be gained by the discussions of an assembly of
physicians from all parts of the world would be, that the con-
tingent of information furnished by each should represent some-
thing peculiar to his country or school. Data, often painfully
gleaned from the records of travellers, would be collected in
abundance by medical observers resident on the spot, and offered
to enrich the common treasure. Moreover, celebrated men,
who had hitherto talked to each other across seas, and through
the medium of books, would meet face to face, would familiarly
converse with each other on the mighty labors by which their
names, their fatherland, had been rendered illustrious, and
derive mutual refreshment from the rare intercourse.

All this I say might have been expected. But the expecta-
tion has been very imperfectly fulfilled. In the first place only
inadequate provision was made in different countries to send
such men as should most justly represent the actual condition
of national science. There should have been official delegates
from the principal universities, who should have been distin-
guished from the crowd of mediocrities who might choose to
attend, but who should not be mistaken for such representatives.
From lack of such precaution, a multitude of opinions were
advanced which were entirely undeserving the sanction of so
solemn an occasion as this professed to be. Any one could speak,
and any one did speak; and, as a rule, the more distinguished
visitors held their tongues.

Not a word from Virchow or Graefe, who were both present;
not a word from Bennett or Simpson. Indeed only two English-
men are on record as having spoken, and not a single American.
The debates were chiefly maintained by the French and Italians.
This was probably in part owing to the very imperfect knowledge
of French that prevails among us Anglo-Saxons, especially the
Americans, and which, as I have had quite frequent occasion to
observe, seriously interferes with the benefit they are able to
derive from a few months' visit to Paris. But the silence also
resulted, in all probability, from the fact that few had prepared
themselves for a sufficiently long time in advance; as a conse-
quence, the topics for discussion were developed in the most

36 Mary Putnam Jacobi

unequal and irregular manner. The minute anatomy of tuber-
culosis occupied two or three sessions, in which nearly all the
speakers were French, who revived old disputes without report-
ing any researches made especially for the Congress. On the
other hand, the three questions that seemed most peculiarly
adapted for international discussion — the influence of various
climates upon menstruation ; the problem of acclimation ; and the
influence of alimentation — were only touched upon in the most
cursory manner. As a whole, therefore, the Congress cannot
be said to have arrived at any valuable result. Nevertheless,
two of the discussions — on the treatment necessary to prevent
purulent infection after surgical operations, and on measures
to be recommended to the governments of various countries to
arrest the spread of syphilitic diseases — ^were exceedingly inter-
esting; and in all the seances, various topics were incidentally
developed that are quite worth recording. I shall endeavor to
mention some of the principal, beginning with those which occu-
pied the least time and attention.

The communications made on the subject of alimentation
were, in accordance with the programme, all written in reference
to pellagra. M. Bouchut has found on grains of wheat spoiled
by the damp, a fungus very similar to that found in the same
circumstances on the maize, to the consumption of which pellagra
is generally attributed. He proposes to name this fungus
sporisorium tritici. To obtain it, it is only necessary to place
some wheat in a jar, and keep it damp.

M. Demaria believes that pellagra is not dependent on an
accidental poisoning, but is a constitutional neurosis, dependent
on hereditary influences and poor food.

The communications of M. Dropsy, of Cracovia, concerning
the Polish Jews, and Mr. Kingston on the Anglo-Canadians,
presented in the course of the discussion on tuberculosis, touch
on a subject of more widely spread interest than the poison of the
maize. Each tends to prove the enormous influence of animal
food upon the preservation of health, especially from the ravages
of phthisis. At Cracovia, the peasants are all healthy and
robust, living much upon animal food. The Jews scarcely spend
more than two sous a day for their nourishment, and never eat
meat. Consumption makes such ravages among them that the
race threatens to die out. In the same way in Canada, the

Letters to the Medical Record 37

French Canadians, who eat meat in excess, often three or four
times a day, are declared by Mr. Kingston (an Englishman) to
be a superb race of people; while their English neighbors, who
live much more soberly, are infinitely more subject to tubercu-
lous disease.

The question of acclimation was as much restricted as that
of the influence of food, being limited to the investigation of the
conditions necessary for acclimating Europeans in warm coun-
tries. M. Simonot read an interesting memoir on the subject.
For him the difficulty did not arise from the heat of the climate,
but the poisonous influence of miasm. Wherever that could not
be destroyed, it was useless to expect to make permanent homes
for white families.

M. Lombard, not adhering strictly to the question, com-
municated the result of researches on the laws of mortality in
Europe, according to atmospheric influences. According to
these, winter and spring is the most sickly season for all the north
and centre of Europe, while the southern countries enjoy their
excess of mortality in summer and autumn. In Europe, miasm
still continues to be one of the most powerful agents influencing
mortality, and it is an agent which in this country it is in the
power of man to remove.

A nimiber of carefully prepared memoirs on the question of
menstruation were communicated; but, as most of them consisted
mainly of statistical tables, they could not be read. The sta-
tistics that were read, by M. Lagneau and M. Joulin, accord very
well with the established law, in virtue of which menstruation is
known to be precocious in warm climates, and retarded in cold.
In English India, the average age for the establishment of puberty
is twelve years and six months. In Norway, sixteen years and
four months. The supposed differences between different cities of
France is shown to be trifling, Marseilles being only six months
earlier than Paris.

Mr. Robert Cowie has made some curious researches upon
menstruation in the Shetland Islands, and its connection with
longevity. In this locality the menses are established at the
same age as in Great Britain, while the menopause, instead of
occurring at forty-five or forty-six years, is deferred to a period
varying from forty-eight to fifty-four years, fifty-one being the
average. In connection with this, Mr. Cowie notices a consid-

38 Mary Putnam Jacobi

erable difference in the rate of mortality, as shown by the
following table:

Sheltand Islands Scotland

Above 70 years = 33.55 per 100. 18.25 per 100.

" 80 " = 20.00 " 7.05 "

" 90 " = 5.03 " 1. 00 "

From 95 to 105 years = 2.68 per 100. 0.29 "

The discussion on tuberculosis was divided into three parts,
severally referring to its pathological anatomy, its prevalence in
different climates, and its treatment. Of these, the first received
much the most attention, not because of its superior importance,
but because it happens to be extremely d la mode at the moment,
and more speakers had something to say on it. The debates
touched on the following questions: First, the specificity of
the tubercle; second, its identity with the products of inflamma-
tion; third, the precise seat of the granular deposit; fourth, the
relation of the yellow degeneration to the gray or crude tubercle;
fifth, and finally, two or three peculiar and rather bizarre opinions
were advanced which had no relation with any of these points.

The question of the specificity of the tubercular deposit may
be variously regarded. A special anatomical element may be
sought, as characteristic of tubercle, but such an attempt was
universally pronounced to be chimerical. On the specific char-
acter of the tuberculous product, either the gray or the cheesy
may be attacked or defended, together or separately. Such a
combat occurred, and was marked by a diversity of arguments,
in support of a diversity of theories. Professor Crocq of Brussels,
and M. Lebert, assimilate completely the tuberculous process to
the inflammatory. M. Crocq began b>- declaring that the cellules
of the gray granulation could be compared to nothing but the
cellules oi the lymph and lymphatic glands, the white globules of
the blood, of mucus, and of pus; in other words, leucocytes,
among which he did not hesitate to class them. In the granula-
tions, these leucocytes are distinguished from pus, chiefly by the
absence of intercellular substance; are small, because bathed by
no liquid, and have only a single nucleus, on account of their low
vitality. These leucocytes arise from the epithelial cells, or
those of the connective tissue, and submit ultimately to fatty
degeneration, etc.

Letters to the Medical Record 39

The phenomena successively exhibited in the formation of
these leucocytes, are identical with those of the cellular elements
of inflamed tissues. When an organ is examined in which
tubercles are developing, it is found strewn with vascular patches.
Sometimes the centre is already consistent and elastic, and at
this centre the tubercle is gradually formed by exudation, since
vascularization and repletion of the tissues by matters destined
to be exuded, is common to inflammation and tubercular forma-
tion. Moreover, in inflammation the cellular elements absorb
new material, swell, become opaque, and finally give birth to
new generations of cells similar to the leucocytes. These, either
in the tubercle or inflammation, have four destinations. First,
they are destroyed, and their materials reabsorbed; second, they
are transformed into new connective cells; third, they swim in an
intercellular liquid, and constitute pus; fourth, they undergo the
fatty degeneration.

It results from these considerations (concludes M. Crocq),
that tuberculization is by no means a specific disease, recognizing
a vice of the blood for cause, but an affection of the same order
as inflammations, and should be combated, like other phleg-
masias, by antiphlogistics and revulsives.

Lebert's views are substantially the same, but are based on
inferences derived from certain experiments made upon animals
by injections of various substances under the skin. In eleven
instances were used the products of chronic pneumonia, chronic
adenitis apparently tuberculous, and tuberculous granulations
of the lungs; two experiments with injections of pus; nine, the
products of expectoration and of pulmonary caverns; ten in-
jections of charcoal or mercury were made into the jugular vein.

The charcoal produced little emboli, followed by cellular
hyperplasma, little granulations, and even multiplication of the
epithelial cells and those of the connective tissue. The mercury
provoked, besides, an inflammation of the vessels; here also,
however, cellular hyperplasma, in the form of little granulations,
and, when the irritation had reached a high degree, formation of
solid inflammatory foci which ultimately suppurated and pro-
duced caverns.

The inoculation of morbid products excited a more severe
local irritation, and also numerous granulations in different
organs.

40 Mary Putnam Jacobi

Hence, for Lebert, the tubercle strictly resembling the granu-
lation thus artificially created, is a product eminently hyper-
plastic, and cannot be classed with accidental products properly
so called.

After this exposition of the pure inflammatory doctrine of
tuberculization, Herard and Cornil rushed to the defence of their
theory, which may be called modified inflammatory. For them,
the gray granulation is the only characteristic lesion of tubercu-
losis which excites an inflammation, whose degeneration consti-
tutes the so-called cheesy tubercle. Neither of these champions
undertook the task of rebutting the views of Crocq or Lebert,
but each addressed himself to that side of the doctrine which
touched upon, and was contradicted by, that of M. Villemain.
This physician has recently made some remarkable experiments
on the inoculation of tubercle, and has succeeded in thus convey-
ing the disease to rabbits. vSo far, his experiments tended to
confirm (at least without the criticism afforded by those of
Lebert) the doctrine of the specificity of the tubercular deposit.
But, proceeding further, he professes to have obtained gray granu-
lations, after inoculation with the yellow cheesy matter. In con-
sequence of this, he renounced the views he had previously held
in regard to that substance, and, no longer believing it to be a
secondary inflammation, he concluded it to be a more advanced
stage of the crude tubercle, thus returning frankly to the ideas of
Laennec. Herard replied that this cheesy pneumonia {pneii-
mome caseeuse) might be sufficiently stamped with the character
of the granulation by which it was caused, to serve as material
for infection; but such did not prove that it was identical with
the granulation which could often be found in its midst, little
changed.

M. Cornil attacked Villemain on another point, namely, in
regard to the seat of the granulation. Villemain, in a memoir
of some length, read at the first session of the Congress, declared
that the greater number of granulations occupy the air- vesicles,
herein again coinciding with Laennec. At the beginning of his
researches, he had considered the contents of the alveoli as a
product belonging to the pulmonary epithelium, and distinct
from the granulation, which is the view actually held by Herard
and Cornil. But subsequently, M. Villemain became convinced
that the membrane of separation between the alveoli was not

Letters to the Medical Record 41

homogeneous, but contained a special element identical in
structure with the connective tissue. In this tissue were de-
posited the greater number of the granulations. He considers
the existence of an epithelial layer at the internal surface of the
alveoli to be extremely problematical.

Hence, he does not believe that the elements constituting the
catarrhal or cheesy pneumonia are derived from epithelial cells,
but from the nucleated cells of the membrane separating the
alveoli. Being much crowded, these cells sometimes assume
plane surfaces from pressure, so as to resemble epithelium; but
they are never soldered together.

M. Villemain admits that the initial stages of tubercle re-
semble those of inflammation, inasmuch as the two external
zones of the three that constitute a tuberculous nodosity, repre-
sent cells in different stages of development; but the two
processes are to be distinguished by the terminations, which for
inflammation is pus, for tubercle fatty degeneration. The
similarity between the anatomical elements of these two states
is, as M. Villemain justly thinks, no reason for identifying
them.

M. Cornil denied point-blank that the tubercle was developed
anywhere but in the lymphatic or adventitious tunic of the
blood-vessels, especially at their bifurcation. This phenomenon
(in tuberculization of the pia mater) is accompanied by two
others: ist. The multiplication of similar elements in the con-
nective tissue of the pia mater which surrounds the diseased
vessel; 2d. The coagulation of the blood, and the retrograde
metamorphosis of the fibrine and blood-globules.

M. Cornil admits that in the lungs there is a development of
elements in the interalveolar membrane. But, besides, he
insists that the large pavement cells, perfectly free, measuring
0.015, are really epithelial, and cannot be confounded with the
elements of the connective tissue, which are small, 0.004, agglu-
tinated, intimately united by a homogeneous and granular sub-
stance. The first constitute the tuberculous pneumonia; the
second the granulation.

A Hungarian physician. Dr. Bakody, warmly supported the
views of Cornil. He moreover suggested that the tubercle
developed especially in the simmiit of the lungs, because there
the respiratory movements are less extensive, and the lungs can-

42 Mary Putnam Jacobi

not readily reject the mass of cells which form in the alveoli in

consequence of inflammatory irritation.

The question concerning tuberculization in different coun-
tries and circumstances was then taken up. M. Marmisse read
a memoir upon the influence of this disease on the mortality at
Bordeaux- The influence of hygienic conditions is indicated by
terribly eloquent figures. Among 1,000 poor people registered
at the Bureau de Bienfaisance, 625 die of phthisis, while the
rich classes only yielded a tribute of 87 on 1,000 to this formidable
disease.

I have already quoted M. Dropsy's remarks on the Jews in
Poland, and Mr. Kingston's on the English in Canada. Dr.
Homan, of Christiania, read a memoir on the disease in Norway,
and its distribution in different sections of the country. The
proportion of deaths from tuberculous diseases in Norway is
about 162 in 1,000. The variations in different districts are from
79 to 226 per 1,000. Sometimes a great difference is observed
between two neighboring districts, which cannot, then, be re-
ferred to difference of climate. Dr. Homan invokes syphilis as
a powerful agent to explain this difference. The capital question
of the treatment of phthisis received no new light.

I must not forget to mention, among the opinions independ-
ently broached, that of M. Empis, who invents a new disease
called granulic, distinct from tuberculosis; and of a physician
whose name escapes me, who declares the cause of tubercle to
be excessive pressure in the blood-vessels, whereby the colloid
matters in the blood are exuded in the form of granulations.

The second great question, on the prevention of accidents
after surgical operations, was developed with much animation.
Two principal opinions obtained : one the perfect efficacy of local
treatment, the other the importance of minute constitutional
care.

One of the most interesting memoirs read in support of the
first theory was that of Professor Bourgade, of Clermont-Ferrand,
on the employment of perchloride of iron. The capital fact
from which the Professor reasons is the different effect produced
by wounds made with a bistoury or with caustic. The latter
are habitually innocuous; the former often followed by serious
accidents of infection. Some surgeons have sought on this
account to substitute the caustic for the bistoury; but that is

Letters to the Medical Record 43

impossible in a large number of cases, and the bistoury will
always remain the surgical instrument par excellence. The
problem is, therefore, to reduce the wound made by it to the same
conditions as that produced by the caustic. This, according to
M. Bourgade, is accomplished by means of the perchloride of
iron, which combines intimately with the tissues, and forms over
the wound a kind of magma solid and adherent, a species of
plastic cuirass, which resembles both a coagulvun and an eschar,
which becomes hard and resistant, and only begins to separate
by suppuration, the sixth, eighth, or tenth day after the opera-
tion. The following is the method for its application : When the
operation is finished, and the arteries suitably tied, the wound
should be washed and dried with the greatest care; and when
the flow of blood is well arrested, the whole surface is covered
with lint saturated in a solution of perchloride of iron at thirty
degrees. It is essential that all parts of the wound, bones,
muscles, cellular tissue, etc., receive the direct action of the
liquid. The whole is covered with moistened lint.

When the tampons of lint fall, they show a blackish surface,
covered with a thin eschar, which gradually detaches itself,
revealing a pink wound in very good condition, already covered
with fleshy granulations.

This method, of course, is only adapted to wounds uniting
by second intention; but, in M. Bourgade's opinion, that is the
only union possible in hospitals. Several surgeons expressed the
opinion that the attempt to obtain union by first intention was
rapidly being abandoned. The perchloride has been applied in
95 operations, all followed with success.

The accidents that are guarded against by the perchloride are
more especially purulent and putrid infection, phlebitis, an-
geioleucitis, osteomyelitis, and consecutive haemorrhages.

The perchloride is supposed to act by a light cauterization of
the bleeding surfaces, and by effecting a solid coagulation even in
the interior of the veins. There results an adhesive and obliter-
ating phlebitis, which prevents the suppurative phlebitis, and
opposes the absorption of morbid elements.

M. Barbosa, delegate from the Portugal government, read
some extracts from an important statistical memoir on the
operations practised for the last twelve years in the hospital St.
Joseph, at Lisbon. They were quite favorable — only 59 deaths

44 Mary Putnam Jacob!

among 243 amputations of limbs; among these, 62 amputations
of the thigh, which gave 29 deaths.

M. Barbosa lays great stress upon the good hygienic condi-
tions of the wards, ventilation, and cleanliness. He adopts the
circular method for amputation, and always dresses the wound
with lint dipped in alcohol saturated with camphor, an ancient
custom in Portugal.

Professor Gosselin followed Barbosa in attaching much more
importance to these circumstances of hygiene than to the local
dressing. He takes especial pains with the morale of his patients,
endeavoring gradually to accustom them to the idea of the opera-
tion, allowing them, whenever it be possible, to name the day,
always securing them from pain by the use of chloroform, etc.
He is also careful to remove the patient as far as possible from
cases of erysipelas, etc., which, unfortunately at La Piti^, cannot
always be very far. After the operation, he is especially careful
to avoid doing anything to cause pain. Never places any ap-
paratus on the stump which will render it necessary to lower or
raise it; does not attempt to draw together the edges of the
wound, and rejects the use of alcohol in the dressing to avoid pain;
places the patients on a mechanical bed, which allows them to be
moved without suffering. By these precautions, out of 48
amputations he succeeded in saving 29 patients, a mortality
of 39 on 100. Of the 19 deaths, 10 only were by purulent
infection.

As an instance of the disastrous influence of moral shock,
M. Gosselin cites the case of a patient who was doing well, when
he heard that his wife had become insane and was at the Sal-
petri^re. Very soon afterward he began to shiver, and fell a
victim to purulent infection.

M. Verneuil, the distinguished surgeon at Lariboisidre,
especially occupied himself with the consideration of the previous
health of the patient. The influence of diseases, manifest or
latent, of the kidneys and lungs, of drunkenness, miasm, etc., is
constantly proved by the unfortunate results of the best con-
ducted operations. M. Verneuil thinks that erysipelas more
frequently occurs in individuals with the herpetic or arthritic
diathesis.

M. Labat attached less importance to previous or coincident
diseases, and agreed with M. Bourgade in the attention needed

Letters to the Medical Record 45

for the local conditions of the wound. He lays down several
rules as follows:

1. Never attempt to obtain immediate union except when
the wound is shallow, the texture of the tissues uniform, the
opposed surfaces can be maintained in contact as well as the
edges, and the tissues have not been too profoundly bruised.

2. Carefully avoid all conditions which may lead to the
alteration of the fluids, and their sojourn near the mouths of the
veins.

3. Favor the draining of fluids by a tube or other means,
establishing a canal from one end of the wound to the other.

4. Avoid the employment of all irritating substances, especi-
ally in regions abundantly provided with l5rmphatics.

5. In anfractuous wounds, fill up the anf ractuosities with lint,
so as to avoid the accumulation of fluids.

6. Preserve the limb as immovable as possible, and avoid
too frequent dressings.

7. Abstain absolutely from the application of pure water on
the wound; always use alcohol.

8. Whenever there is reason to fear purulent absorption, give
ergotine in the dose of two to three grammes from the first day,
and continue as long as the danger lasts, usually ten or twelve
days.

A distinguished professor from Rome, M. Mazzoni, pointed
out the necessity of isolating the surgical wards from those con-
taining fever or tuberculous patients, a precaution hardly ever
adopted in French hospitals ; but at Naples, Professor Palasciano
did not hesitate to tender his resignation when the attempt was
made to approach a fever ward near that of his operated patients.
M. Mazzoni asserted the comparative immunity of the Italian
hospitals, even the maternities, from erysipelas and puerperal
fever, in all cases except where the usual precautions to exclude
patients affected with fevers or other contagious diseases, or with
tuberculosis, are for some reason neglected.

Mr. Meric, of London, also claimed for the English hospitals
the merit of great attention to this point, and ascribed to it much
of the superior success of English surgeons in ovariotomy.

But sometimes the most lively debates of the entire Congress
were excited by the question of syphilis, and its means of preven-
tion by legal measures. With the exception of Dr. Drysdale of

46 Mary Putnam Jacobi

London, and one other physician who wished to oppose moral
education to the extension of the frightful evil, it was everywhere
assumed that the only efficacious measures consisted in strict
surveillance over prostitutes. In proof of the results obtained
by this means, several members read elaborate memoirs. The
first was sent by M. Wleminckx of Brussels, who pronounces
that to be the best regulated of cities in this respect. All the
registered public women are examined every three days, and
punished if they fail to present themselves for examination.
Upon the slightest suspicion of disease they are sent to the
hospital. All physicians are forbidden to treat prostitutes at
their houses. Rewards are offered to such women as present
themselves regularly for examination. By means of these
precautions, M. Wleminckx asserts that the number of syphilitic
diseases has very considerably abated, and secondary and terti-
ary affections have nearly disappeared.

In addition to these measures applied to women, in military
hospitals all syphilitic patients are rewarded if they will denounce
the person from whom they have contracted the disease.

M. Crocq, also from Belgium, observed that these measures,
so efficacious in the great cities, were neglected in small villages,
which served as places of refuge for clandestine prostitution, and
were indestructible foci of syphilis.

M. Rollet, in the name of the Imperial Society of Medicine
at Lyons, advocated not only surveillance of the women, but of
all men in situations where their conduct could be controlled, as
soldiers, sailors, etc. In view especially of the terrible accidents
recently occurring at a large glass factory, where the workmen
being compelled to apply their mouths successively to the same
tube, nearly all contracted the disease from one whose mouth was
the seat of syphilitic ulceration, M. Rollet recommends the
extension of this surveillance to the glass-blowers also.

M. Buchon made a report of the measures actually enforced
in the French navy. Every sailor or soldier is submitted to an
examination, previously to the arrival of the vessel in port, and
none are permitted to go on shore without a certificate of perfect
health. Same precautions before leaves of absence are granted.
Thanks to this incessant surveillance, which although of ancient
date has been especially vigorous since 1830, the navy department
has greatly diminished the number of syphilitic patients admitted

Letters to the Medical Record 47

into the hospitals. At Brest, where the hospital formerly always
contained three hundred beds of such patients, the number has
diminished to one hundred.

M. Le Fort presented some statistics concerning the actual
state of prostitution in Paris. The total number of registered
prostitutes is 3,851, of which 1,306 are distributed among one
hundred and sixty-five houses — the rest are isolaterl. The
amount of clandestine prostitution is enormous, but cannot be
estimated. All soldiers treated for the disease are compelled to
reveal its source, and the police pursue the woman. A certain
number of girls are arrested every day for clandestine prostitu-
tion; among 13,818 of this category, 3,728 were found to be dis-
eased, 1,131 were sent to St. Lazare, 7,217 reclaimed as minors by
their families (!), 1,549 or^Y were registered.

In six years 504,000 examinations have been made with the
speculum upon prostitutes, and 3,720 contagious diseases have
been thus discovered. This number is small in comparison to
the number of examinations, but considerable in proportion to the
number of prostitutes registered.

In spite of all this surveillance, as Mr. Drysdale of London
remarked, syphilis is not less frequent in Paris than London,
where prostitution receives no sanction from authoritative sur-
veillance.

The question that really excited the Congress almost to a
flame, was that of the possibility of preventing syphilis by inocu-
lation. It is unnecessary to record the debate in which M. Ricord
quite overbore M. Auzias-Turenne, who enthusiastically advo-
cated such inoculation. Several very disastrous and even fatal
diseases were reported by those who adhered to Ricord's doctrine,
as the consequence of inoculation with the hard chancre. The
discussion had no especial result.

Complementary sessions were held from time to time in the
evening, in which various interesting subjects were suggested or
debated. I have already over-passed my space, but must men-
tion two communications of real curiosity.

The first is the exposition, by M. Brunetti, of a new method
for preserving anatomical pieces. His preparations have been
on exhibition at the Exposition, but the process hitherto has
been kept secret. In an evening session, however, M. Brunetti
revealed it; and, as I know from personal examination of his

48 Mary Putnam Jacobi

preparation^, the results are so admirable, that every one should
be acquainted with the method.

Several operations are included; the washing of the piece
freeing it from fat, its tanning and desiccation.

To wash the piece, M. Brunetti passes a current of pure water
through the blood-vessels and excreting canals; then alcohol to
expel the water.

Then ether is made to replace the alcohol in order to dissolve
the fat; this process requires several hours. The ether penetrates
everywhere, and everjrwhere accomplishes its work thoroughly.
At this point, the piece plunged in ether can be preserved in-
definitely before proceeding to further operations.

Then tannin is dissolved in boiling distilled water, and this
solution is passed into the blood-vessels, etc., after the ether has
been driven out by a current of distilled water.

Then the piece is dried by being placed in a vase with a
double bottom, and containing between the two, boiling water.
By means of a reservoir where the air is compressed to about two
atmospheres, and which communicates by a stopcock and a sys-
tem of tubes, first with a vessel containing chloride of lime, then
with another empty and heated, then with the vessels and ex-
creting canals of the piece, M. Brunetti establishes a gaseous
current which expels all the liquids. The operation is then
finished, and the piece remains supple, light, with its natural
size and relations, and all its solid histological elements. The
most perfect microscopic slices may be made from the
preparation.

The other invention, which is too good, or at least too strik-
ing, to be passed by in silence, is an instrument for Somatoscopy.
This was presented by M. Millot, of Russia, and is designed to
illuminate the cavities of the body, so as to render them trans-
parent to the eye. The apparatus is composed of a glass tube
containing a platinum wire curled up on itself, and communicat-
ing by copper stems with the two poles of an electric battery.
When the current is passed, the platinum wire grows glowing
white, and emits an intense light. This tube introduced into the
stomach, vagina, or rectum of the cadaver, has enabled the
observer to see by transparence the walls of the abdomen. M.
Millot made some experiments upon animals before the Congress,
but so far he has had no opportunity to test his apparatus on the

Letters to the Medical Record 49

living subject. He hopes, however, by its means to bring great
assistance to the diagnosis of tumors of the ovary, and even
adherences, and also of calculi and tumors of the bladder.

P. C. M.

To the Editor of the Medical Record.

Sir — To-day celebrates the closure of the Exposition; to-
morrow will witness the reopening of the Ecole de Medecine, and
the beginning of the long medical year.

In Paris, the ceremonies of the year are reserved for its close
as in Italy, while in England, as in Spain and Portugal, whatever
solemnities are deemed fitting to dignify the old critical days of
the scholastic season are observed at the moment of its recom-
mencement. L' Union Medicate, of Paris, in reviewing the cele-
brations held at the different schools, greatly commends the
simpHcity of the English, who quietly assemble at the numerous
"head-centres" of instruction, listen to a regulation address, and
immediately set to work at their studies ; whereas, in Madrid and
Lisbon the affair is made a state occasion, honored by the presence
of the king and highest public functionaries. It is pomp versus
utility, says Dr. Simplice, and the contrast is manifest even in the
themes chosen by the professors for the address. That of Mr.
Graily Hewitt, for example, at the University College in London,
was entitled, "The Therapeutic Utility of Alimentation," while
the discourse of Professor Alonzo at Madrid was devoted to an
elaborate exposition of "The Benefits of Instruction."

In Italy, the illustrious Professor Tommasi celebrated the
close of the year of official instruction by a retrospective review of
the most important clinical facts that have presented themselves
to his observation since its commencement. M. Tommasi
energetically insists on the sufficiency of clinical study to meet
its own legitimate ends, and protests against the prevailing tend-
ency to accept the ideas of Chomel and degrade it into a simple
stepping-stone for pathological anatomy.

"Clinical study alone has established the causal relations between articular
rhetunatism and endocarditis, between alcoholism and arthritis on one side,
and endo-arteritis on the other, between different species of constitutional
infection and an increase in the volume of the spleen, between syphilis and
certain special neoplasias of the connective tissue, between scarlatina and
croupal inflammation of the pharynx and kidneys."

50 Mary Putnam Jacob!

You remember that Continental physicians (not including,
however, the French) are agreed to denominate all inflammations
attended with fibrinous exudation croupal.

Epilepsy Depending upon Premature Ossification of the Cranial
Sutures.

Among other interesting facts quoted from his clinic, Tom-
masi signalizes a case of epilepsy in a child, dependant upon
premature ossification of the cranial sutures, especially the
spino-occipital. This cause of epilepsy has been specially signal-
ized by Virchow. In Tommasi's case, the disease was greatly
ameliorated by the use of nitrate of silver, but it is difficult to
imagine why.

Concerning Ptisans.

The use of ptisans is so widely spread in France, where cold-
water drinking is considered at once an imbecility and a crime,
that their selection becomes a matter of considerable importance.
M. Miquel (de Tours) has just published some suggestions on the
drinks most suitable in typhoid fever that might be not altogether
useless at home. He proscribes all amylaceous and sugared
mucilaginous drinks, especially those containing vegetable acids,
and all fermentable preparations, on the ground that they in-
crease the secretion of bile, and the confluence of the intestinal
eruption. Therefore, instead of lemonade, currant jelly, gum
and barley water, M. Maquel recommends infusions of linden and
orange leaves, chamomile and mignonette; also water flavored
with a few drops of coffee, tea, brandy, or rum. In preparing
rice water, mixed with decoctions of poppy heads, the physician
of Tours directs that the rice be not added to the decoction ready
made, but only allowed to remain in contact with it long enough
for the water to extract the astringent principle of its rind.

Dyspepsia and Its Treatment.

M. Malherbe, of Nantes, publishes some reflections on a
subject calculated to interest the inmost heart of every American
— on the treatment, namely, of dyspepsia. Considering that, in
our favored land, all the blessings of liberty are impotent to save
us from the grasp of this foul fiend, and that nearly every one
of us has either had dyspepsia, or actually suffers from it. or is

Letters to the Medical Record 51

destined to suffer in the future; no suggestions on the subject can
afford to be lost. M. Malherbe strongly recommends the use
of pure hydrochloric acid in all cases of the atonic form of the dis-
ease. He considers this substance to act as a stimulating tonic,
which facilitates stomachal digestion by assisting to dissolve
albuminous substances; by regulating the secretion of gastric
juice; by remedying constipation in virtue of an exciting action
on the intestine; finally, by a tonic action on the general economy.
In various cachexias, even advanced tuberculosis, this medicine is
found to render good service. I have myself had an opportunity
of testing the truth of this observation, especially at Laribois-
siere, in the wards of M. Herard. He is enabled, by means of
this acid, to greatly relieve the various dyspeptic symptoms
(among which frequent vomiting is not the least painful) which
torment the last days of his numerous consumptive patients.

It is recommended to associate wine of quinquina, calumba,
or rhubarb, and some preparation of opium with the hydro-
chloric acid. The following is the formula employed at the Hotel
Dieu of Nantes:

Wine of Quinquina lOO grms.

Syrup Thebaic 30 "

Pure Hydrochlor. Acid i "

Mix.

The dose is from two to six teaspoonfuls a day. To relieve
the gastralgic pain to which many dyspeptics are martyrs,
M. Miquel suggests the administration of a concentrated opiate
combined with a bitter, which serves to correct its injurious
effects. The following is his formula:

Syrup of Bitter Orange Peel, ")

" Morphine >■ aa q.s.

Ether J

Mix.

Where the pain comes on principally before eating, it is
advisable to administer a narcotic or etherized draught about a
quarter of an hour before meals. It is M. Herard's practice to
give his patients ten drops of Sydenham laudanum immediately
before, and one grm. of pepsine immediately after eating. This
treatment entirely relieved the pain, and stopped the vomiting in

52 Mary Putnam Jacobi

the case of a woman, who subsequently died from the effects of a
diarrhoea maintained by deep tuberculous ulcerations of the
intestines, and with whom the mucous membrane of the stomach
presented the signs of such an intense arborescent injection,
mingled with yellow and slate-colored spots, as really merited
the title of gastritis.

Arsenic in Cerebral Congestions.

Therapeutics does not constitute atpresent the most fashion-
able subject of meditation in the medical world, so much the
more, therefore, do I glean studiously all indications of experi-
ment in this direction. M. Lisle had just read a note before the
Academy on the advantages of arsenic in the treatment of inter-
current cerebral congestion among the insane. M. Lisle con-
siders hallucinations to be, not a symptom, but a complication of
insanity, and always dependent upon congestion, consequently
always to be treated by arsenious acid. He claims to have cured
131 patients out of 193 by the use of this medicament, and to
have markedly ameliorated the condition of twenty-nine others.
If the facts cited by M. Lisle are trustworthy (and there is no
reason to suppose they are not) they are in striking opposition
with his theory. According to the analogy of its action in all
other cases, arsenious acid should be considered as an eminent
tonic of nutrition, regulating the life of the capillaries, perhaps, in
several ways, but by no means tending to disgorge them of un-
seemly congestion. At the hospital Beaujon, M. Montard
Martin told me that he employed arsenious acid with consider-
able success against cholera in the last epidemic, and there
seemed reason to suppose that the capillary circulation of the
surface was restored or stimulated by this potent drug in a
manner to relieve the deadly visceral congestion. Moreover, as
the editor of the Montpellier Medical remarks, it is far from
proved that hallucinations are connected with congestion of the
brain, a condition not indicated merely by some redness of the
face and brilliancy of the eyes. According to the ideas of Luys
in his recent brilliant researches into the minute anatomy of the
cerebro-spinal system, hallucinations occur when the thalami
optici instead of simply receiving impressions from without and
irridating them to the periphery, set up an independent action,
and originate impressions in the recesses of their own structure.

Letters to the Medical Record 53

This might occur whether they were excited by congestion or
their normal functions perturbed by anaemia.

For those who have not read M. Luys' book, it may be
necessary to explain that many of his views on the structure
of the brain are quite original. The particular theory to which
I have just referred rests on another, purely anatomic, namely,
that all sensitive fibres proceeding from the posterior and lateral
columns of the spinal cord, are destined to terminate in the thai-
ami optici, which constitutes the first receptacle and halting
place for impressions received from the world without. Here
the crude impressions are elaborated and ultimately radiated to
the vesicular matter of the convolutions along the converging white
fibres that apparently proceed from the surface to the base of the
brain. These are not, as generally affirmed, the mere continu-
ation of the fibres from the cord, but new ones, deriving their
origin from the thalami optici themselves.

The Characters of Cerebral Softening.

In this connection it is natural to mention the essay in the
Archives de Medicine, written by Proust, on softening of the
brain. The dominant idea resulting from the researches of this
distinguished young physician, is the separation of softening
{ramoUissement) both from encephalitis and haemorrhage.
Encephalitis determines a neoplasia, or is equivalent to it,
precisely as inflammation generally involves the idea of exudation.

Heemorrhage usually results from the rupture of a capillary
aneurism. But ramoUissement is a necrobiosis, essentially the
same as gangrene of the limbs, and its phenomena only differ
because the tissues involved are withdrawn from the action of
the air. M. Proust, however, reserves the name necrobiosis
for a molecular destruction of tissue, and to its destruction en
masse assigns the term necrosis.

The death of the cerebral substance depends upon obstruc-
tion of the capillary circulation, however caused, whether by a
thrombus, an embolus, stricture of the cerebral arteries, fatty
degeneration of the capillaries, thrombus and phlebitis of the
sinus, etc. In these cases, there may be produced either a condi-
tion of aneemia or of hyperaemia. If an obstacle to the circu-
lation be situated in the sinus, there is always hypereemia;
obstacle in the capillaries occasions rather anaemia. The first pro-

54 Mary Putnam Jacobi

duces the red, the second the white softening. Hyperaemia of the
parts surrounding the focus of softening is easily explained by the
collateral fluxion in branches of the vessel whose tension has
been increased by the obstacle to the circulation. Hyperaemia
of the centre of the infarctus is more difficult to account for, and
M. Proust only suggests with some hesitation, that it may be
due to some action on the part of the vaso-motor nerves, or the
result of a functional alteration of the capillaries.

The white coloration is rarely observed, but occurs occasion-
ally in cases of general cachexia, as in the case of cancerous
patients.

The red coloration may be uniform, and is then more marked
at the periphery; or spotted, and then results from little haemor-
rhages arising from the rupture of a great number of capillaries.

Diminution of the consistence of the part is appreciable from
the second day. The tissue has a trembling jelly-form appear-
ance. Then the part becomes tumefied, it is softer, the furrows
separating, the convolutions disappear, and by the third or fourth
day it has become reduced to a diffluent paste.

The first phenomenon detected by the microscope is the
appearance of fatty granulations in filtering the tissue. These
have been observed at the end of twenty-two hours by Charcot,
and thirty-six hours by Prevost and Cotard. Then granular
bodies succeed to these fatty granulations and accompany them.
According to Bouchard these granular bodies consist of agglomer-
ations of fatty granulations.

Transformations speedily take place, corresponding to what
has been described under the name of chronic softening, plaques
jaunes, cellular infiltration. The coloring matter of the blood
transudes through the walls of the capillaries; that already cxtra-
vasated becomes converted into yellow granular amorphous
masses, or else into reddish oblique rhomboidal crystals, the
hasmatoidine of Virchow.

Later, a neoplastic effort sets up, and a tendency to cicatri-
zation appears; the pia mater contracts adhesions with the
bottom of the excavation that has been formed by resorption
of disorganized tissue, and across this excavation are extended
laminae of connective tissue. The tissue surrounding the soft-
ened part becomes slightly indurated in virtue of a proliferation
of nuclei and cells. This last is analogous to the formation

Letters to the Medical Record 55

of an eliminating membrane around a patch of gangrene in a
limb.

Prdvost and Cotard, under the direction of Vulpian, have
made a number of experiments on the production of foci of
ramollissement by injection into the arteries of powder of lycopo-
dium or tobacco. They succeeded in simultaneously provoking
infarctus in the brain, the spleen, and the kidneys, were able to
observe the apparition of fatty granulations and granular bodies,
and determine the formation of plagues jaunes.

Although the opinions have been refuted which attached
softening to inflammation, on account of a mistaken idea that the
yellow degeneration consisted of pus, Proust admits that certain
analogies exist between the two affections, especially in the
formation of the zone of proliferation. Further, that it is im-
possible to say that heemorrhage and softening exercise no mutual
influence on each other; on the contrary, the first tends to destroy
the tissue directly, and to cut off its nutrition, or, on the other hand,
the second, by withdrawing from the capillary walls their normal
support, predisposes them to yield to the pressure of the blood.

The influence of atheroma upon the production of haemorrhage
is of course unquestionable. I had an opportunity of observing
a remarkable illustration in an autopsy recently performed at La
Charite. The aorta was atheromatous from its base to a point
below the cross; the carotids were sprinkled with atheromatous
patches, but arrived at the brain, the internal carotid showed
complete degeneration. The same was true of the branches
of the basilar artery. In this brain, sections in any direction
revealed a punctuated injection caused by rupture of the capil-
laries, and in the middle lobe of each side, adjoining the thalami
optici, existed a small focus of haemorrhage.
Truly yours,

P. C. M.

Paris, Nov. 3, 1867.

Curious Nervous Phenomena.

To the Editor of the Medical Record.

Sir — The "sensation" of the week centres around the
discussion of a remarkable circumstance occurring in the wards
of M. Richet at Hotel Dieu. On the 23d of October, a woman

56 Mary Putnam Jacobi

entered the service, who, falling against some pieces of sheet
copper, had been wounded in the forearm by their sharp edge, in
such a manner that the radial artery and median nerve had been
completely divided. Notwithstanding this section, sensibility
remained in the thumb, index and middle fingers, and the exter-
nal border of the ring finger, all furnished by the median nerve;
moreover, the peripheric extremity of this nerve was exquisitely
sensitive to the touch of the pincers.

The fact has been examined and acknowledged by a number
of distinguished physicians. There can be no doubt that the
median was completely severed. But it is difficult to explain a
phenomenon so contrary to the facts which form the basis of
current physiological theories, according to which the peripheric
extremity of a severed motor nerve preserves its motor power, and
that of a sensitive nerve loses its sensibility. Dr. Fort, in the
Union Medicale, endeavors to prove that the case is one of recur-
rent sensibility, like that described by Bernard as existing in the
facial nerve. Irritation of this nerve excites pain, on account of
its anastomoses with the trigeminus. In the same way, says
Dr. Fort, we must infer from this fact itself that the radial and
cubital nerves furnish anastomoses with the median, by which
this latter is enabled to preserve its sensibility even after section.

This argument is rather post factum. Moreover, as ob-
served by Dr. Reveillant in the Gazette des Hopitaux, there is no
analogy between the coupling of a sensitive and motor nerve in a
single "nervous pair" (as in the case of the 5th and the 7th) and
this supposed anastomosis between two sensitive nerves, which
is justified by no precedent whatever. Dr. Reveillant maintains,
that since the grand palmar nerve is more deeply situated than
the median at the wrist on the level of the wound, since it is
united to the median only by a loose cellular tissue which permits
great mobility, since the median was torn, instead of being dis-
tinctly cut, and the wound was deepest on the radial border of
the wrist — in view of these considerations it is probable that the
great palmar nerve was not divided, as at first supposed, and the
recurrent sensibility was due to its presence in the parts furnished
by the median. But this explanation, though hypothetically
satisfactory for the sensibility remaining in the hand, renders
no account of that preserved in the peripheric extremity of the
median, since the palmar branch is given off from this latter

Letters to the Medical Record 57

nerve at a point above the situation of the wound, and after-
ward has no connection with the median. Dr. Richet has not yet
spoken. His detailed description of the case is presently ex-
pected, and may throw light on this vexed question.

Experiments upon Criminals.

At the naval medical school of Brest, M. le professeur Duval
has pursued some physiological researches in a direction that
continually tends to become restricted. If the humanitarian
tendencies of the age prevail, capital punishment will be abolished
and physiologists for ever deprived of the bodies of criminals as
material for experiments. In view of this unfortunate con-
tingency, all experiments actually performed are invested with a
double interest, on account of the possibility that they may be
the last permitted in civilized countries.

The following is a resume of the results obtained by M.
Duval, in galvanization of the different apparatus of the bodies of
criminals, within five or six minutes after their execution.

Nervous System. — Galvanization of the motor ocular nerve,
at its point of immersion in the cavernous sinus, caused instant
contraction of the dilated pupil. In two subjects reflex move-
ments were excited by a brusque tap on the hands or feet. The
contractions of the deltoid, brachial, biceps, anterior tibial and
gastro-nervous muscles were especially evident. In the case of
a slight irritation of the surface, exciting contraction of the sub-
jacent muscles, the action was evidently reflex: where a smart
percussion had been practised, M. Duval supposes that the
muscular fibre had been directly excited, independent of the
nerves. This experiment confirms Schiff's refutation of the
theory that warm-blooded animals could not exhibit reflex
movements after decapitation.

Digestive Apparatus. — The stomach and small intestines
continued to exhibit peristaltic movements for several minutes.
The stomach was filled with food, and in the midst of digestion,
but none of its contents escaped at the orifices after removal of
the organ from the abdomen, so efficient was the contraction of
the sphincters. A remarkable prominence of the solitary closed
follicles of the ilium was observed. This fact is interesting, on
account of a theory recently proposed, which considers such
prominence to be a characteristic lesion of cholera.

58 Mary Putnam Jacobi

Circulatory Apparatus. — The primitive carotids were divided,
and their extremities were seen to rise at regular intervals, elon-
gate beyond the level of the wound, and then subside; at each
impulse a small quantity of frothy vermilion blood escaped.

On the same two subjects, the thorax was opened seven
minutes after death, and the heart found to be beating within
the pericardium. Upon incision of this membrane, the following
succession of phenomena was observed. At the beginning of
each movement the auricular appendix was suddenly raised, and
distanced from the aorta, then fell as abruptly into its primitive
position. In rising, the appendix lengthened, and the indentures
of the circumferences parated like the fingers of an outstretched
hand. At the same time with this erection of the appendix,
occurred an expansion of the auricle, as if it were distended by an
efflux of liquid. The contraction of the ventricles followed
that of the auricles in less than the fifth of a second. These
cavities were shortened in all their diameters, their surface
became furrowed, they contracted together in perfect
S3nichronism.

After cessation of the spontaneous beatings of the heart,
the movements were renewed by the application of galvanism,
first to the organ itself, afterward to the spinal cord.

M. Duval found that a moderate degree of contractility
existed in the walls of the aorta, which, irritated by the insertion
of a finger, were found to slightly press upon it.

Respiratory Apparatus. — Upon galvanization of the external
or internal intercostal muscles, or of both together, the under rib
was raised and pushed outward. M. Duval concludes that both
these muscles, concerning which, from the time of Haller and
Hamberger, there has been so much discussion, are inspiratory.
M. Duchenne (de Boulogne) impresses this fact into his service
to prove the same theory.

Atrophy of Muscles of Trunk and Limbs.

I am not sure whether I have mentioned the lecture delivered
by Duchenne upon a patient in the wards of M. Bouillaud,
affected with atrophy of nearly all the external muscles of the
trunk and limbs. The intercostal muscles were entirely wasted,
and the chest is flattened in a remarkable manner. The
respiration is performed by the diaphragm. M. Duchenne

Letters to the Medical Record 59

remarked, that since the thorax contracted, as in expiration, as
soon as the intercostal muscles became powerless, it was just
to infer that in health they antagonized this contraction; that
is, opposed the action of the expiratory muscles. It seems to me
evident, however, that the case in question proved that they
exerted such antagonism in virtue of their tonicity, not at all on
account of the intermittent contraction during inspiration. The
experiments of M. Duval are no more conclusive, for although a
muscular fibre when galvanized should elevate a rib to which its
fibres were attached, we are not thence to infer that it contracts
habitually during life, or therefore that it directly elevates the

ribs during inspiration.

P. C. M.

To the Editor of the Medical Record.

Sir — Before the Academy of Sciences, M. Sappey presented
a note announcing the existence of nervi nervorum, or nervous
filaments, in the neurilemma of nerves, analogous to the vascular
ramifications in the coats of blood-vessels. The distinguished
anatomist has followed these filaments as far as the sheaths
enveloping the secondary trunks of nerves, but they are never
found in the envelope of primitive fascicules. The internal
envelope of the optic nerve receives no nervous filament. The
external, on the contrary, receives a number from the ciliary
nerves. This external sheath is also remarkable for the abund-
ance of elastic fibres which enter into its composition. It
therefore differs notably from both the sclerotic and the dura
mater, which are deficient both in nervous filaments and elastic
fibres.

The Curvature of the Spine and the Ossification of the Ribs.

M. Sappey is the Chef des Travaux Anatomiques, and has
just reopened his popular course at the Ecole Pratique. At a
lecture at which I had the pleasure of "assisting" the other day,
M. Sappey referred to two points which had been the object of
some recent personal researches, and may not, therefore, be well
known to you. One was an explanation of the curvatures of the
vertebral column by the obliquity, in the cervical region of the
intervertebral disks, in the dorsal, of the bodies of the vertebrae,
and in the lumbar, of both bodies and disks. Hirschfeld had

6o Mary Putnam Jacobi

attributed these curvatures to the action of the yellow ligament,
and declared that they were destroyed by its section. M.
Sappey had repeated the experiment, and found this assertion
incorrect — the curvatures persisting.

The other point referred to was the ossification of the ribs.
According to M. Sappey, the ribs, like the bones of the craniiun
and the face, pass through no cartilaginous stage, but a thread of
osseous substance is found to be formed directly in the midst of
the original "mucous" mass.

The Function of the Vaso-Motor Nerves.

Drs. Eulenbers and Landois have published a series of articles
upon the function of the vaso motor nerves, and upon the r61e
they seem to play in a certain intermittent ophthalmia. Grie-
singer considers this affection to be a form of latent intermittent
fever, as a neuralgia of the eye more or less severe, accom-
panied by congestion more or less intense. It is nearly always
unilateral, and consists in an intense hyperasmia of the eye,
with photophobia, suffusion, contraction of the pupil, and often
oedema of the iris. When the disease is of long standing, it may
terminate in chronic ophthalmia, or in atrophy of the bulb.
Griesinger considered the presence of neuralgia essential to
characterize this form of ophthalmia, but Mannhardt has
reported a case where this symptom was entirely wanting.

A man thirty-six years old was suddenly attacked at nine
o'clock in the morning with an acute catarrhal conjunctivitis.
Intense redness and swelling of the palpebral and bulbar con-
junctiva, abundant flow of tears mixed with mucous flocculi. A
collyrium of acetate of lead was ordered. The next morning
there was no trace of the affection but it returned with as much
intensity as ever at two o'clock in the afternoon. The same
collyrium was employed, and the inflammation again disappeared,
to reappear the fifth day between nine and two o'clock. Small
doses of quinine were then ordered. An access of moderate
intensity occurred the seventh day, but from the ninth the dis-
ease did not return.

It may therefore be admitted that the vaso-motor filaments
of the trigeminus may be affected independently of the sensitive
fibres and that intermittent ophthalmia may exist uncompli-
cated by neuralgia.

Letters to the Medical Record 6i

Curious Phenomena Presented by Primitive Syphilitic Indiu"a-
tions.

In the Archives of Medicine for November, M. Foumier, a
distinguished agrege of the faculty, has called attention to certain
curious phenomena occasionally presented by primitive syphilitic
indurations. The first and most interesting is an ulceration of
the cicatrized chancre. The second is the softening of the cen-
tral and deep portions of the induration, and its progressive
elimination in the form of a purulent detritus. The third pheno-
menon relates to the production of secondary indurations, result-
ing from the primitive affection, and occurring in the neighbor-
hood of the initial chancre.

In the first case, the physician may have had to deal with a
chancre which has accomplished its different phases with perfect
regularity, and has cicatrized in a perfectly satisfactory and
apparently definite manner. Under certain circumstances (of
which an unusual abundance of the induration seems the most
characteristic) this cicatrix is found to open, ulcerate, and erode
in various points; — a new wound is thus formed on the surface
of the induration, which sometimes excavates its entire extent.
M. Foumier has observed this secondary ulceration to be repeated
three times on the same base. In the cases in question the
rupture of the chancre is entirely spontaneous.

Although in the greater number of cases the ulceration takes
place on chancres in which the induration is excessive, it may
also occur when this is of only medium intensity. The ulcer is
formed from the eighth and fifteenth days after the cicatrization.
Sometimes it is quite superficial, a simple erosion; sometimes it
affects the excavated form. A sanguinolent rather than puru-
lent liquid is secreted by the wound. The ulcer generally heals
with remarkable rapidity, and, although sometimes alarming
from its extensive and ragged aspect, it is in reality benign.
Even when assuming a phagedenic form, it readily heals with
only an application of dry lint.

The conversion of the cicatrized chancre into an abscess,
much more rarely occurs than its ulceration. In this case, also,
the cicatrix has been regularly formed, and the induration is
generally excessive. Presently the centre of the mass is felt to be
softened, and a little later a small opening is discovered, through
which is eliminated a yellowish sanguinolent liquid, puriform

62 Mary Putnam Jacobi

rather than purulent. As many as six openings have been
observed, each leading by a curiously formed little passage into a
central focus of softening. The integrity of the outer layers of
the mass is preserved.

It is evident that the ulcer and the abscess are really analogous
lesions, each producing a liquefaction and consecutive elimin-
ation of the pathological tissue of the induration. May not the
exaggeration of this latter, which has been found so generally
to coincide with the lesions, be indirectly their cause, on accoimt
of opposing greater difficulty to the ordinary process of absorption ?

The secondary indurations may ulcerate, and assume the
aspect of primitive hard chancres. M. Foumier thinks that it is
on account of cases of this kind that Babington had been led to
maintain that syphilitic induration preceded ulceration. An
opinion that M. Foumier has no hesitation in pronouncing
erroneous, if only on account of the difficulty of diagnosis between
initial chancre and herpes.

Operations for Naso-Pharyngeal Polypus.

The Gazette des Hopitaux contains an account of an interesting
operation practised at the Hotel Dieu of Clermont Ferrand, for a
naso-pharyngeal polypus. The patient was a boy of eighteen,
extremely diminutive and fragile. The polypus had apparently
existed eighteen months. The right cheek was but slightly
deformed, but the difficulty of speaking, and the embarrassment
of the respiration, forcing the patient to keep the mouth partially
open, indicated the existence of a material obstacle to the
entrance of air.

The soft palate was pushed forward by a hard, resistant,
bright-red tumor, whose lower border projected below the uvula,
its adherent edge mounted in the pharynx. The nostril of the same
side was obstructed by a fleshy mass, evidently only an expansion
of the guttural tumor.

The finger, introduced between the cheek and the alveolar
arcade of the upper maxilla, distinguished a small tubercle
which corresponded to the exterior tumor. The point of insertion
was difficult to determine; nevertheless it seemed probable that
the tumor adhered rather to the pharynx than to the nasal fossa.

After some delays, during which the respiration became
more and more embarrassed, M. Fleury determined to afford the

Letters to the Medical Record 63

patient the only chance for life that remained, by practising
the resection of a portion of the maxilla, and thus extracting the
tumor. The patient being under the influence of chloroform,
an oblique incision was made from the commissure of the lips to
the external angle of the orbit. Only one artery required
ligature. The upper flap was dissected to a considerable dis-
tance, then a chain saw introduced by means of a curved needle
into the spheno-maxillary cleft, to separate the maxilla from the
malar bone. The second lateral incisor tooth was extracted, and
the cisailles, introduced into the mouth and right nostril, easily
divided the palatine vault — a section practised with scissors
separated the apophysis of the maxilla ; it then was only necessary
to apply the blade of the same instrument underneath the orbit
and exercise a light pressure, to loosen the bone. The soft parts
uniting it to the subjacent tissues were detached with curved
scissors, and the bone then easily removed. The nasal fossa and
zygomatic cavity were thus laid open, and the opening, though
smaller than if the maxilla had been entirely removed, was
sufficiently large to give passage to the tumor, and the risk of
deformity was much less than would have been incurred by the
other operation. The polypus being discovered, was much
larger than had been supposed, since it occupied the cavities
of the face. As much as practicable, M. Fleury endeavored to
enucleate the tumor. The pedicle was implanted by a large and
resistant base in the upper part of the pharynx. It was for-
tunately but slightly vascular, and the slight hsemorrhage
following its division was easily arrested by the cautery. The
tumor weighed 112 grains, and was nearly entirely flbrous.

The second day after the operation, inflammation of consider-
able intensity set up around the wound, and destroyed all hope of
union by first intention. The following days a suspicious odor
escaped from the mouth and nostrils, which was partially neu-
tralized by lotions of chlorinated soda. The patient was ex-
tremely feeble, and a fatal termination was dreaded. How-
ever, after some days of uncertainty, the lips of the wound,
which had opened, assumed a better appearance and became
covered with healthy granulations, the patient was able to
rise, to eat, and from that moment the convalescence was
assured.

The inflammation was attributed in part to the use of the

64 Mary Putnam Jacobi

actual cautery. The wound was dressed with lint steeped in
camphorated alcohol.

This is the third case in which M. Fleury has saved a patient
from inevitable death, by boldly venturing on this formidable
operation on the maxilla.

Among the clinics recommenced with the reopening of the
year, that of M. Gosselin, who has succeeded the lamented
Velpeau at La Charite, is not the least interesting. The inaug-
ural lesson was divided into three parts. In the first the new
professor paid a just tribute to the memory of his predecessor.
In the second, he traced a rapid sketch of the history of this
famous hospital, founded by Marie de' Medici 260 years ago.
During 150 years there was no clinic, and the names of no surg-
eons have come down to us. The first illustrious clinician of the
Charite was Desault, who instituted the concours for the position
of assistant surgeon. Deschamps was the first who obtained
this title, and also the first who availed himself in his scientific
writings of observations taken among his hospital patients.
Until then, observations had always been collected from the
writer's private clientele. Of all the writings of Deschamps, the
best known are his "Observations on the Ligature of the Principal
Arteries of the Extremities, on Account of Wounds or Aneur-
isms." Boyer succeeded Deschamps, and Roux followed Boyer;
finally Velpeau took the place of Roux, when the latter suc-
ceeded to Dupuytren at Hotel Dieu.

The third part of the lesson was devoted to two patients in
the wards, one with a fracture of the wrist, the other with an
encysted encephaloid tumor at the internal and lower part of the
thigh. Space does not permit me to quote at length M. Gos-
selin's remarks, further than that, in the latter case, he con-
sidered that amputation would not prevent a return of the
tumor, but would prolong life.

P. C. M.

To the Editor of the Medical Record.

Sir — You will remember, no doubt, that at the International
Congress the theme which opened the debates, and which
occupied a most prominent place in the discussions, was the
apparently exhausted subject of tuberculosis. M. Villemin has
just offered to the Academy the treatise of which his remarks

Letters to the Medical Record 65

at the Congress were the abstract, the exposition, and the
defence. The researches of this ingenious experimentalist have
led him to conclusions differing so widely from those generally
adopted, as to excite the curiosity, applause, or indignation
of every defender of the medical faith. Hence the report of M.
Colin on Villemin's book has been followed by an able and lively
discussion of unexpected interest in connection with a disease
which had, so to speak, fallen into disuse, and whose victims
were regarded as useless incumbrances of the clinical wards
in the hospitals.

Inoculability of Tubercle.

The novelty of Villemin's views is manifested on three
important points, ist. Denying the existence of epithelium
in the pulmonary alveoli, the physician of Val-de-Grace contra-
dicts Reinhardt's assurance that the cheesy masses occupy the
air-cells, and ascribes to them the same origin and seat as that
generally admitted for the gray granulations, viz. the connective
tissue between the alveoli, and around the blood-vessels. These
masses are the result of fatty degeneration of the plasmatic
elements of the connective tissue, whose proliferation has given
rise to the nuclei and small cells characteristic of the centre of
the gray tubercle. These last elements invariably degenerate,
but not unfrequently the large connective cells on the periphery
of the granulation are also invaded while yet undergoing the pro-
cess of multiplication. In this respect therefore, Villemin returns
squarely to the views of Laennec, who regarded the cheesy
masses as softened tubercles.

2d. The most remarkable part of the Etudes sur la Tuberculose
is that which relates to the experiments on inoculation of tuber-
culous matter, some of whose results were submitted to the
Academy in 1865. Villemin was induced to make these experi-
ments, by observing the histological resemblance of the ele-
ments of the miliary tubercle with those of the tubercle of
syphilis or glanders. Since they were specific and inoculable,
he inferred that the gray granulation might be so as well. The
second half of this supposition has been fully confirmed. An
immense number of experiments have been performed upon
rabbits, by inserting into the subcutaneous cellular tissue frag-
ments of pulmonary tubercles, and in nearly all cases the injection

66 Mary Putnam Jacobi

was followed by an eruption of miliary granulations in the lungs,
and by the constitutional symptoms of tuberculosis, to which,
after awhile, the animals succumbed.

3d. Upon the success of these experiments, the first of any
consequence that have ever been made in this direction, M.
Villemin bases an entirely new theory of tuberculosis. He claims
that what is inoculable must be specific; that tuberculosis
belongs, in its character of specificity, to a family of diseases,
depending on the substantial introduction into the system of a
peculiar animal virus. It is, in short, a definite, virulent, con-
tagious disease, like syphilis and glanders; and the histological
similarity between the tumors in the three cases is justified, so to
speak, by their family or generic affinity.

Now, as to the reality of the results obtained by M. Villemin
in his experiments, there can be no doubt. They have been
repeated with equal success by M. Colin, who reports the new
treatise to the Academy; their accuracy is acknowledged by M.
Cornil, from whose party Villemin has made such a frightful
secession. Bouchard, in his review in the Gazette Hehdomadaire,
and Chauffard and Pidoux in their speeches at the Academy, all
admit this striking and unexpected discovery — viz. that tuber-
culosis, anatomically and clinically characteristic, may be com-
municated to rabbits and guinea-pigs by inoculation from the
tubercles of cattle or human beings.

But the inferences adopted by M. Villemin are extremely con-
testable and contested, as M. Chauffard by an anatomical, M.
Pidoux by a general analysis, successfully disproved the pre-
tended virulence of the tubercular deposit. Chauffard points
out that inoculations of specific animal poisons, as those of
syphilis, small-pox, hydrophobia, etc., are first made with fluids
containing no morphological elements or special characteristics.
But Villemin's favorite experiments consisted in grafting a definite
structure upon the organism. When this structure, sown on
soil rendered congenial by the presence of l>Tnphatics, develops
itself and excites the surrounding tissues to similar proliferation,
it does so in virtue of the laws of development of tumors, which,
according to Virchow, depend on the foundation of a tissue by
elements coming from another tissue.

2d. A definite period of incubation is essential to the process
of virulent inoculation; after which appears local trouble, speedily

Letters to the Medical Record 67

followed by general symptoms of infection. But M. Colin shows
that in the experiments there is no such incubation, and no
reproduction of the tubercle on the place where it was inocu-
lated. The tumefaction observed there results from the resist-
ance offered by the tubercle to the dissolving action of altered pus,
on account of which some of the matter originally introduced may
often be found on the same spot six weeks afterwards. M. Pid-
oux declares that the tubercle, placed at the base of the scale of
heteroplastic formations, multiplying like all inferior organisms,
dying speedily, and infecting the locality with products of decom-
position, is in the highest degree incapable of the incubating
force, the latent and refractory vitality characteristic of virus.

3d. The gray granulations are possessed of no exclusive power
of infection. Villemin himself has produced an eruption of
miliary tubercles by inoculation of the cheesy detritus, and even
admits this to be the most favorable for the experiment. It is
on this fact that he bases the revival of the doctrine of identity
between the cheesy mass and the crude tubercle. M. Colin has
successfully inoculated various animals, rabbits, guinea-pigs,
lambs, calves, and dogs, not only with the cheesy deposit, but
with the hard cretaceous tubercle from the lungs of oxen. Clarck
has succeeded with ordinary pus ; and Empis with pus from puer-
peral peritonitis, from the surface of Peyer's patches ulcerated
in typhoid fever, and from suppurating fibrinous pneumonia.
Finally, Lebert has experimented with mineral substances, as
mercury and carbon. In all these cases a crop of perfectly char-
acteristic gray, hard, semi-transparent tubercles was obtained in
the lungs of the animals submitted to the experiment. It is
impossible to imagine a more complete demonstration of the
common and non-specific origin of the crude tubercle.

4th. M. Colin, in his report, follows step by step the conse-
quences of the inoculations, and shows that for a long time they
are purely local. The disease is communicated, not by the
general infection of the whole system, but by the implantation of
a thorn, whose irritation gradually extends and involves the
lungs. The focus of inoculation is presently surrounded by
radiating white lines, formed by lymphatic vessels engorged with
foreign matters. The ganglia in which these vessels terminate
engorge themselves also, and become filled with tubercular
granulations, and others in their turn. The ganglia not found on

68 Mary Putnam Jacobi

the route traversed by the morbid vessels, remain perfectly
sound. From the lymphatic system, the tuberculous matter
gains the central organs, probably by the route of the circulation,
and is thus gradually deposited in the lungs, liver, spleen, and
kidneys. This evolution is exactly that of the gradual propa-
gation of a local evil, not the simultaneous impregnation of the
entire organism by a virulent agent.

Colin is so impressed by this local character of the disease
artifically produced, that he jumps to the conclusion that natural
phthisis is also the result of local mischief, resulting from one or
more tubercles that have at some time been introduced into the
economy, and after remaining latent for an indefinite period, are
suddenly awakened to activity. But this supposition is entirely
gratuitous.

5th. M. Pidoux dwells upon Villemin's admission that the
yellow tuberculous matter is more active than the gray tubercle.
If we assume (which, as we shall presently see, is conceding too
much) that this cheesy deposit be in fact a degeneration of the
tubercle, a striking contrast becomes apparent between the
tubercle and virus. This is more active in its first stages than at
the period of its degeneration.

6th. Pidoux also observes that the similarity between the
histological structure of the tuberculous tumor and of syphilis
and glanders, is really an argument against the virulent character
of the first affection. For at the moment that the other two
diseases have resulted in tumors, they have ceased to be virulent,
and have passed into a state of diathesis. Inoculation from those
tumors will give rise to neither glanders nor syphilis. Hence
this grand foundation-stone of the new theory, and this initial
observation of M. Villemin's researches, is wrenched from him,
and turned most ingeniously into a powerful argument against
his cause.

From this critique it appears that inoculation of tuberculous or
other matter acts on the lungs (whither it has been brought by
the blood, and arrested by the fine network of capillaries), by
irritation of the plasmatic cells of the connective tissue. These,
proliferating, give rise to the small elements, which, closely
crowded together, constitute the gray tubercle. The process is
closely analogous to the proliferation of inflammation, which
also results in the formation of the small cells and nuclei of pus,

Letters to the Medical Record 69

which cannot by their form be distinguished from those of the
crude tubercle. The difference consists — first, in the intercellu-
lar substance, liquid in pus, finely granular in the tubercle; second,
in that the fatty degeneration results in cheesy masses for the
tubercle, while the pus remains liquid.

In all cases of artificially induced disease the irritation comes,
of course, from without, and may be called local. This may
occur also, as Pidoux observes, in acquired phthisis, especially in
that of miners and others constantly exposed to direct irritation
of the lungs. But in constitutional and hereditary consiimption
the tubercular process is to be regarded simply as the final stage
to which all irritative processes in weakly subjects naturally tend
to degenerate.

"The impoverishment of the field of nutrition is the first
condition of tuberculosis," says Pidoux; "the occurrence of some
irritation the second. Nothing is more susceptible of irritation
than weakness, nothing so ready to degenerate." Again (for I
quote willingly from this able and brilliant discourse in which the
old colleague of Trousseau so well justifies his reputation),

tuberculosis is the constitutional alteration, the characteristic and organic
heteroplasia of the lymphatic apparatus, the fundamental apparatus of
nutrition. This is attacked in the connective tissue, which constitutes its
base. When this tissue sustains what Hunter calls the stimulus of imperfection,
it is excited to proliferations, imperfect, sickly, of an extremely ephemeral
vitality, born in fact but to die; such is the tubercle.

Chauffard ingeniously suggests that the ease with which the
tubercle may be inoculated depends precisely upon the poverty
of its organization. The fecundating tissue, to refer again to
Virchow's idea and expression, would need to make less effort
to assimilate another to a feebly organized structure, than to one
complex, rich, and characteristic; and from this point of view
the inoculation of tubercle is more easily comprehensible than
that of cancer.

But the existence of an internal cause for tuberculosis,
of a diathesis and of hereditary tendency, is denied by M. Ville-
min, and it is this denial that constitutes the fame of his heresy.
He is as frank a believer in the contagious origin of phthisis as a
doctor of the sixteenth century, or an Italian or Spanish peasant
of the present day. For him reunions of consumptives constitute

70 Mary Putnam Jacobi

more deadly foci of infection than cholera hospitals, and the
lives of the patients sent to Nice and Cannes are terribly short-
ened by the atmosphere impregnated with emanations from the
reeking lungs of their fellow-sufferers.

Upon this point especially does M. Pidoux attack the inno-
vator. He charges him, not unfairly, with having entirely
neglected the clinical study of tuberculosis in his absorption in
its anatomical pathology. Examination of lungs after death
is extremely useful as a means of ascertaining the results of disease
and many of its processes, but must usually be incompetent to
determine its cause. And it is glaringly illogical to conclude
that because in a given case a disease has been artificially pro-
duced by inoculation of certain substances from without, there-
fore all spontaneous cases of the affection depended on the same
mechanism. As well argue that capillary bronchitis could only
be caused by injection of snuff into the trachea.

Yet precisely to this complexion has come M. Villemin. He
formally denies the possibility of any spontaneous alteration
of the organism, and insists that all disease must result from the
infliction of exterior agents. Thus, from the reformed basis of
phthisis, he dares attempt the reform of all pathology. But, as
Pidoux observes, all exterior agents would be without effect
were it not for a susceptibility on the part of the organism to be
affected, which capacity itself constitutes a spontaneity and
individuality.

In the meantime M. Pidoux is far from claiming for phthisis
that overwhelmingly predestined character with which it is
popularly associated. He admits that about one-sixth of all
consumptive patients contract the disease in virtue of direct
hereditary influence, but that many others are predisposed on
account of transformed hereditary influence; arthritism, herpctism
syphilis, or scrofula in the parents, tending less to reproduce
themselves in the children than to occasion pulmonary tuber-
culosis.

Similarly, phthisis springs up in the wake of many diseases,
which at their height are directly antagonistic to it. This is the
case especially with arthritism, whose remains seem as it were
to enrich the soil of the economy, and prepare it for phthisis.
Such transformation takes place with the same individual. But
in hereditary transmission M. Pidoux announces as a sufficiently

Letters to the Medical Record 71

definite law, the progress of capital or initial diseases, first
towards mixed diseases, then those that are ultimate or organic.
Thus arthritism, scrofula, syphilis, capital diseases, change into
herpetism, neuroses, neuralgias, catarrhs, etc., or mixed diseases;
and these in turn degenerate into organic diseases, as tuberculosis,
cancer, epilepsy, and incurable degenerations of the nervous
centres. M. Villemin entirely denies any connection between
scrofula and tuberculosis, which is the more singular as he cannot
ignore the readiness with which the lymphatic glands become the
seat of cheesy degenerations, such as he identifies with tubercle.
It is precisely because he is forced to admit the multiple origin
of scrofula, that he seeks to separate it from tuberculosis, of which
the specific character must be preserved at all hazards. Pidoux,
fully conceding the difference between the two diseases, justly
insists on their frequent etiological connections. Scrofula is the
initial chronic disease, often superficial, curable, and not an
organic malady, although capable of becoming so. Tuberculosis,
and especially pulmonary phthisis, are ultimate and organic
diseases, too often the final stage of non-tuberculous affection.
It is quite as necessary for scrofula as for arthritism or syphilis to
degenerate before it gives rise to tuberculosis; patients with
scrofulous ulcers are not consumptive, but lymphatic constitu-
tions, delicate, nervous, "civilized," fall an easy prey to phthi-
sis, often because of their escape from the external manifestation
of the disease.

Finally, it is unquestionable that a number of persons un-
tainted by hereditary vice of constitution, and uninjured by
previous disease, fall victims to consumption on account of
exposure to cold, to want, to privations. Pidoux seems to imply
that in these cases the disease commences in bronchitis, deter-
mining proliferations of alveolar epithelium, which degenerates
into cheesy masses, which ultimately excite a crop of tubercles by
irritation of the connective tissue. Pidoux, therefore, fully
admits the German distinction between pneumonic phthisis and
granular phthisis ; the last being constitutional, the fi.rst accidental,
and often extremely rapid. Bouchard adheres also to this view,
and sums up the differences between the gray tubercle and yellow
masses, which nearly, if not quite, demonstrate their indepen-
dence of origin. In the first stages of the "cheesy pneumonia,"
as the yellow masses are called by the new-school pathologists,

72 Mary Putnam Jacobi

the alveoli are found partially filled with large pavement cells,
which, in spite of M. Villemin's assertions, reveal their epithelial
character by being more or less soldered together. The alveoli
also contain serous exudation. On the contrary, the first stage
of the granulation consists of a mass of small spheric cells, 0™ ^,
008 in diameter, with the nucleus filling the cavity almost com-
pletely, closely pressed against each other. This mass is situated
not in the alveoli, but in the connective tissue at the bifurcation
of the blood-vessels. In the second stage of catarrhal pneumonia
the liquid is absorbed, the anatomical elements accumulate
and become infiltrated with fat, and presently the alveoli are
rendered entirely impermeable to the air, and offer on section
a smooth level surface uniformly gray and homogeneous. The
granulations also submit to the cheesy degeneration, but for a
long time retain their form, so that different zones are dis-
tinguishable in their mass.

Villemin's second thesis, therefore, which constitutes his
remarkable discovery, is everywhere confirmed, and it is an ac-
quired fact that it is possible to produce pulmonary phthisis
artificially, by inoculation with tubercular deposit, or with the
products of the pneumonia accompanying, determining, or
determined by that deposit. But his first theory, that identifies
the ^tubercle and the pneumonia, and his third, which would
make of phthisis a specific virulent disease, seem to be sufficiently
refutable and refuted.

I only mention in passing the theory of contagion, for that is
confessedly based on no clinical facts, but those dubious ones
that have already done service for this theory. M. Villemin
seems to infer that the contagion of phthisis must be a necessary
consequence of its inoculability. But this is evidently a strained
conclusion, since the conceivable mode of transmission between
human beings must be widely different from that practised by
Villemin on his rabbits. The hateful practical consequences
of this doctrine of contagion may justify, perhaps, a partiality for
M. Pidoux's vehement denunciation of its possibility. I have
ventured to devote so much space to this discussion (of which I
have endeavored to render the substance, but have been unable
to transfer the zest and animation) , because it is one of the most
important that has taken place in Paris for some time. The
daily urgent practical need of interest in pulmonary consumption

Letters to the Medical Record 73

is so great that even a scientific vagary that should rouse the
flagging attention to a worn-out theme, would be of value. This
book of M. Villemin's, however, is no vagary or frivolity, as you
may judge from the elaborate report that has been made of
it to the Academy, and from the spirited debate to which it has
given rise. But, in spite of its ability, and the great interest of
the experimental researches, it is a reaction in a sorrowful direc-
tion. All hopes of curing phthisis depend upon its nature as a
general disease of common origin; and the theory which tends
to make it specific condemns the physician to inertia, or the vain
revival of forgotten specific antidotes. It is with pleasure,
therefore, that I find that M. Villemin's arguments are less sound
than they are brilliant, imposing, and endowed with the charm
of novelty. P. C. M.

Paris, January 2, 1868.

Concerning Aphasia.

To the Editor of the Medical Record,

Sir — Americans are bound by every natural principle to
oppose the tendency to centralization, which, like a dose of
hashish, serves to concentrate the consciousness of entire France
upon its head, Paris. We may most profitably and agreeably ful-
fil this duty by giving a hospitable reception to the medical
and scientific news so richly furnished by the provinces.

One of the most interesting memoirs that have appeared
during the past fortnight was read at the Imperial Society of
Medicine, at Marseilles, by Dr. Fabre, wherein are discussed,
with much clearness and originality, three problems concerning
aphasia, a disease whose symptoms and pathology are so remark-
able and mysterious.

A fourfold division is made of the disease. In the first
variety or degree the patient forgets words; in the second, he
loses voluntary control over their formation; in the third, he
ceases to understand their meaning ; finally, all these conditions
may coexist in the most complex form of aphasia.

The loss of the faculty for written language, which is so
remarkable a secondary phenomenon of aphasia, also exists in
four degrees. In the first, the patient loses all recollection of
written letters or words, but is able perfectly well to copy models

74 Mary Putnam Jacobi

placed before him. In the second, he is unable to write, even
when understanding what he wishes to transcribe. In the third
case, he has lost the faculty of reading; and if he tries to write,
although he succeeds sometimes in forming the letters well, he
cannot co-ordinate them into words. Finally, all understanding
of written or spoken language may have been completely
abolished, while the rest of the intellectual faculties remain
completely intact.

It is remarkable that when aphasic patients are unable to
express their wishes, either by words or gestures, they sometimes
succeed in giving utterance to their feelings. Thus, a lively sense
of gratitude inspired a patient at Hotel Dieu to utter the only
word that he pronounced in the ward; he said "merci" to the rSH-
gieuse who was taking care of him.

In the first class, there are various degrees of forgetfulness.
Some patients forget proper names, or the greater number of
substantives, and express their meaning by circumlocution.
Thus, instead of asking for a pen, they demand something to
write with. Others cannot construct a complete sentence. In
the second class the patients pronounce words differently from
what they intend; and although conscious of their mistake,
and irritated by it, they are unable to rectify it. After this
simple perversion of language comes real impotence ; the patients
express all their meaning with the same word, or even syllable,
often utterly devoid of sense. Thus a patient of Trousseau's
always repeated the word consist, and the syllable tan constituted
the entire vocabulary of a patient of Broca's. With these pa-
tients the movements of the tongue are perfectly free, and there is
not a trace of glosso-labio-pharyngeal paralysis.

In the third category, the functional trouble is less grave,
as regards the mechanism of speech, and more serious in respect
to intellectual disorder. The patients cease to understand the
meaning of their own words, and when they wish to say one thing,
express a meaning directly the opposite. Thus a lady receiving
visitors, addressed them in terms of gross insult, supposing that
she simply invited them to be seated.

In the most complete cases of aphasia, from the testimony of
certain physicians who have been affected by it and recovered,
the intelligence is still perfectly intact. Thus Rostan observed
his own case, and mentally prepared a clinical lecture upon it.

Letters to the Medical Record 75

Lordah, and Dr. Spalding of Berlin, had a similar experience.
Whatever difficulty is encountered in intellectual exertion is not a
cause of the aphasia, but a result, on account of the loss of signs
necessary to give precision and support to thought.

M. Fabre enters at length into the discussion of the anatomical
locality for the lesion in aphasia. He inclines entirely to the
opinion that, in the majority of cases, the left frontal lobe is the
seat of the disease. Four or five cases have, however, been
reported, in which a destruction of both the anterior lobes was
unaccompanied by any symptom of aphasia. In these cases,
however, the posterior part of the lobes was nearly intact.
Moreover, M. Fabre suggests, although the faculty of speech be
specially localized in this part of the brain, that in case of need,
other portions might sometimes supplement its action.

Again, autopsies of aphasic patients have not unfrequently
revealed lesions of various parts of the encephalon, other than
the frontal lobe. But it is easily conceivable that the fibres from
this locality, in passing through diseased portions of brain
substance, should become affected, even though their centre re-
mained healthy. In this case the cause of the aphasia would
be no indication of the seat of the faculty of speech. It is
presumable, moreover, that there exist varieties in the lesions, to
which the clinical varieties correspond. In permanent aphasia,
the lesion generally consists in softening, especially such as results
from obliteration of the middle cerebral artery. Such obliter-
ation frequently determines a hemiplegia at the same time, on
account of the distribution of the artery to the corpus striatum.
In cases of sudden hemiplegia, M. Fabre considers that the coin-
cidence of aphasia alone permits the diagnosis of obliteration
instead of hsemorrhage, as the cause of the accident.

Transitory aphasia either depends upon neuroses, as hysteria
or epilepsy, or is attributed to congestions. But M. Fabre is
incHned to rule out this last circumstance, and substitute obliter-
ations of artereoles, which caase a temporary derangement of the
nutrition. After a while the development of collateral circu-
lation renews the nutritive activity of the region, and the
patients recover.

No therapeutic indication can at present be based upon this
fact of arterial obliteration as the most common cause of aphasia,
but it may tend to prevent the trial of useless or untimely measures.

76 Mary Putnam Jacobi

Pulmonary Emboli as a Consequence of Congelation of the
Limbs.

At Strasbourg, the opening lecture of the course of operative
surgery, delivered by Professor Michel, consisted in an interest-
ing study upon pulmonary emboli as a consequence of congelation
of the limbs. At first sight this consequence seems to be ex-
tremely far fetched, but the links are easily traced by means of
such experiments as those made by M. Powchet on animals.
The following are the conclusions of a memoir submitted by him
to the Academy :

1st. The first phenomenon produced by the cold is the
contraction of the capillary vessels to such an extent that no
globule can enter them.

2d. Presently the blood globules begin to alter, become
granular, opaque, crumpled on the edges. If only the limbs
have been frozen, about the fifteenth or twentieth part of the
globules are altered; but if the entire body has submitted to the
cold, nearly all the globules are disorganized. In this case, the
animal dies inevitably.

3d. When the congelation is partial, the frozen part is
destroyed by gangrene. If it be of small extent, the amount of
disorganized globules poured into the blood is often not sufficient
to compromise life.

4th. If a large extent of surface has been frozen, and then
suddenly thawed, so that a quantity of disorganized blood glo-
bules are thrown into the circulation, the animal is liable to die on
account of this alteration of the blood, and by no means in
consequence of stupefaction of the nervous system. Hence it
follows that the chances of life are increased in proportion to the
moderation with which the thawing-out process is conducted.

M. Michel, supported by the case of a patient at the hospital,
who exhibited symptoms of asphyxia after her frozen feet had
been thawed, admits that the danger results, not merely from the
presence of disorganized globules in the blood, but their presence
in the pulmonary capillaries. The accidents occur only after
sufficient time has elapsed for the formation of clots from dead
globules, then separation from the main mass in the large veins,
and their arrival in the lungs. Here are found obstructing the
capillaries, long clots, containing little whitish grains which seem
evidently to be formed by altered blood globules, fat globules, and

Letters to the Medical Record 77

fusiform epithelial cells. The more recent clots surrounding
these grains, and the infarctus found in the pulmonary paren-
chyma, prove an arrest of the current of blood in the lung, on
account of their presence in the capillaries. These lesions ex-
plain the symptoms observed in such cases, the frequency of the
respiration supplementing the impermeable portions of the lung,
the presence of rales due to the sero-sanguinolent exudation that
succeeds the embarrassment of the circulation, the bluish tint of
the face, coinciding with a certain pallor of the skin. Death
may result from syncope caused by the simultaneous formation
of a great number of the pulmonary emboli in the capillaries, or
even, and more suddenly, by the obstruction of the pulmonary
aorta itself. Larrey relates a case during the Russian campaign,
where this seems to have happened: "The chief pharmaceutist,
Zurean, arrived at Kawno, exhausted with hunger and cold,
and passed several hours in a warm room. Immediately his
frozen limbs became swollen, and he expired without uttering a
word."

One of two destinies is reserved for the microscopic clots of
blood globules. They either degenerate, and in consequence of
their molecular disorganization the capillaries are reopened; or
they organize by means of the development of fusiform cells, and
then the capillaries are definitely obstructed. The method of
elimination from the general circulation is at present unknown.

In either of the foregoing cases, the patient may recover.
The danger is aways in proportion to the extent of the lesion,
and the suddenness with which it is produced.

Uterine Retroversion During Pregnancy

Dr. Vignard, of Nantes, communicates to the Journal de V
Quest, two observations of uterine retroversion occurring, one at
the third month, the other at the fourth month of pregnancy.

In the first case, a difficulty of micturition existed for several
days, and was followed by an attack at night of acute hypogastric
colic, accompanied by intense vesical tenesmus. In the morning
these symptoms abated, to give place to severe pains in the back
and the groins, and particularly, a most painful pressure on the
rectum. On examination, a tumor was discovered in the hypo-
gastric region, extending 10-12 centimetres above the symphysis.
This was formed by the distended bladder.

78 Mary Putnam Jacobi

By the vaginal touch, an immobile tumor was discovered,
extending from the sacral concavity to the pubes, and forming
to the vagina a convex roof, perfectly uniform, but slightly in-
clined downwards and backwards. The neck of the uterus was
discovered with difficulty, forcibly pressed against the upper
part of the posterior face of the pubes. No fluctuation was per-
ceived between the hand placed on the vesical tumor and the
finger pressed against the tumor in the vagina. Pressure on the
abdomen did not in the least affect the roof of the vagina.

The bladder and rectum were evacuated by the sound, and
an injection, and the physician then attempted the reduction of
the uterus. After various methods had been tried in vain, the
following proved succe?sful :

The patient was placed on the back, the head tolerably
low, the thighs separated widely, the feet on two high chairs, and
the pelvis supported on a pillow placed at the edge of the bed.
The physician then introduced the four fingers of the right hand,
one after another, into the vagina, and taking with the left hand a
point d'appid on the pubes, he forcibly pushed the uterus in a
direction directly upwards. The tumor did not budge. Upon
this the tactics were changed, and the operator directed his
fingers forcibly, but with extreme slowness, toward the sacro-
vertebral angle, gliding around the tumor, and keeping the radial
border of the hand as near as possible to the pubic arch. It was
tolerably easy to arrive at the promontory, and at the same mo-
ment the uterus seemed mobilized. Upon withdrawing his hand,
Dr. Vignard discovered the neck of the womb returned to the
centre of the vagina. Abdominal palpitation discovered the
body of the uterus above the pubes, replacing the void that had
been left after the evacuation of the bladder. The only indica-
tions afforded during the operation that the reduction had been
effected, were the slight mobility of the uterus, and the contact
of the fingers with the sacro-vertebral angle. Dr. Vignard
thinks that the operator may be sure that he has succeeded, every
time that the diameter sacro-sus-pubien can be occupied by the
radial border of the hand.

The patient was recommended to recline upon the abdomen
during the first day, and the uterus retained its normal position.
The subsequent pregnancy and the accouchement were un-
accompanied by accident, but the child, who had vomited bile in

Letters to the Medical Record 79

the amnion, continued to vomit after birth, and died in seventeen
hours, with the signs of acute peritonitis.

In the second case, the third degree of retroversion seemed
to have been attained, and the vaginal cavity was completely
occupied by a globular body, warm, firm, elastic, that seemed to
be the posterior face of the uterus. The neck forcibly flexed, was
discovered high up behind the pubes. The retention of urine
was considerable, but easily relieved by catheterism. The
reduction was first attempted by the attending physician, but he
found it impossible to raise the uterus above the superior strait.
M. Vignard then practised the manoeuvre already described.
The four fingers were pushed directly backwards in the sacro-
pubien diameter of the pelvis, while the radial border of the hand
pressed forcibly against the pubic arch. The pressure was as
moderate as possible, to avoid injury to the foetus. At the
moment that the fingers touched the upper part of the sacrum, a
faint crackling sound was heard, the resistance was felt to be
vanquished, and the vagina free. On withdrawing the hand,
the neck of the womb was found returned to its place. The
patient continued her pregnancy in safety, and was delivered at
term of a healthy child.

M. Vignard passes in review several methods that have been
proposed for remedying this serious accident of retroversion.

The method of Burns consists in placing the patient on the
belly, and keeping the bladder perfectly empty by repeated
catheterism. This method can only be successful in the first
degree, in which the long axis of the uterus is parallel to the sacro-
pubic diameter. This, however, was the case in Vignard's first
observation, but the method was tried and failed.

Boyer's direction, to draw down the neck of the womb at the
same moment that the body is pushed upwards, is regarded as at
least superfluous, since the neck returns of itself when the im-
mobility of the body has been overcome.

Moreau's plan of hooking the index finger around the neck,
is condemned as futile.

Negrier introduces the entire hand into the vagina, and pushes
the uterus en masse as in certain methods for reducing hernias.
A very large surface is here attacked at once, the tumor is flattened,
and the inferior portion therefore increased in size, so that the
method is more painful and more difficult than that of Vignard.

8o Mary Putnam Jacobi

M. Vignard rejects all methods by the rectum, because the
hand will find more difficulty in reaching the promontory by this
route than by the vagina, and all eflforts to push the uterus di-
rectly upward tend merely to press it against the promontory which
forms an insuperable barrier to its ascent. In resuming his own
method, M, Vignard observes, that before directing the fingers
toward the sacrum, he pushes upward on the anterior part of the
uterus, and then glides toward the body of the organ behind.

Tumors of the Tongue and Pharynx — New Operation

M. Desgranges publishes in the Journal de Lyon, certain
considerations on tumors of the tongue and pharynx, and a special
method for operating upon them. This method belongs to M.
Sedillot, and consists of a section of the lower maxilla on the
median line, by means of which the two halves of the bone could
be drawn aside and sufficient space left to excise the tumor. The
wound of the soft parts heals readily, but for the cicatrization of
the segments of the maxilla it was found necessary to maintain
the adjustment by means of pincers. This instrument presents
certain inconveniences, and M. Desgranges has used metallic
sutures instead, piercing the bone with a drill, for the passage of
the silver wire.

Two cases are related where this operation was successfully
performed for an epithelial cancer of the floor of the mouth. In
the first case, the tumor, situated under the tongue, extended
from the first molar of the left side to the canine at the right.
The posterior face of the maxilla was invaded, and the incisors
and left canine were partially loosened from the alveoli.

In operating, the integuments were divided as far as the hyoid
bone, then the section of the maxilla effected by the chain saw.
Care was taken that the section should be made at the left side,
and the insertions of the genio-hyoid and genio-glossal muscles of
the right side avoided. Upon separating the segments of the
bone, the diseased parts were easily removed with curved scissors,
without touching the subjacent muscles. No blood fell into the
pharynx, so that suffocation was avoided. The results were
most happy. The tongue retained its movements, and no trouble
occurred in the respiration. The two halves of the maxilla
were not displaced, and when the patient left the hospital three
weeks after the operation, a fibrous callus united the segments,

Letters to the Medical Record 8i

and with sufficient solidity to permit movements of the entire
jaw.

In the second case, the tumor had burrowed more deeply, and
was ulcerated. The superficial layers of muscles were removed,
but enough remained to insure the movements of the tongue.
The operation, performed exactly as in the preceding case,
was followed by a slight attack of erysipelas, and it was a month
before the two halves of the divided maxilla ceased to shake
in the movements of the lower jaw. But in six weeks the osseous
union was complete.

This preliminary osteotomy opens a free route to the bis-
toury ; it enables the operator to examine the entire tumor, and to
pursue its prolongations, a circumstance essential as a guarantee
against relapse. Moreover, the extreme difficulty of ligating
the numerous arteries encountered in this region is greatly pal-
liated, and finally, the danger avoided of suffocation during the
anaesthetic sleep, on account of blood flowing into the larynx.

P. C. M.

The Appointment of Hospital Internes in Paris — Interesting
Cases from Cliniques of M, Gosselin

To the Editor of the Medical Record.

Sir — I cannot resist the opportunity to say a word on the
admirable system that obtains in Paris for the regulation of the
hospital studies of the pupils. Admirable both for its democratic
equity in throwing open the best clinical advantages to all who
choose to try for them, and for the stimulating pressure that it
exerts on the mental exertions of the young men. Instead of
private cliques surrounding each hospital physician — consisting
of his paying students, to whom his only equivalent for three
hundred dollars is the prospect of nomination to a vacant place
in the wards — there is a perfectly free competition by means of
nomination before a jury.

Two sorts of places are directed to be filled by the students in
the hospitals. The lowest is that of externe. An exteme is
obliged to be on hand at every morning visit (a certain number
of absences in the course of a year occasions the forfeiture of the
place), and with his companions, records the prescriptions, and
performs certain personal services required for the patients, as the

82 Mary Putnam Jacobi

dressing of wounds, application of blisters, &c. A definite
number of externes is attached to each service, the number vary-
ing, of course, with the extent of the service. To secure a place
in this body, a medical student inscribes himself for the tria-
examinations, which are conducted on two year subjects given at
the moment, one pathological, the other anatomical. Two
examinations take place at each concours. In the first the candi-
dates prepare written answers to the questions, during a half
hour allotted for the purpose. Upon the results of this prelimin-
ary examination, a certain number of candidates are estimated,
and the selected minority are submitted to a second final examin-
ation of the same nature, but which is oral. The number of
places to be filled each year, is sufficiently large to give nearly
every serious student a chance for the external.

For the place of interne, corresponding to what we call
resident physician, the externes alone are eligible candidates.
There are about forty-five places, and two hundred and eighty
competitors.

The examinations (which occupy two or three months) are
of the same character as those of the external, only considerably
more difficult. An externe generally calculates to compete
twice before he succeeds in becoming interne. To prepare
for these competitions, the candidates hold conferences in groups
of twenty or thirty, that continue throughout the year previous
to the moment of trial, and in which the entire outlines of internal
and external pathology are passed in review.

An externe is nominated for three years, an interne for four;
and each year is passed at a different hospital. A person may
become a competitor for either position at any stage of his medical
studies at which he feels himself sufficiently jort to stand the
examination.

It is plain that the benefits of this system — great as they are
to the students who succeed at the examinations — extend also to
those who fail, since all are equally compelled to prolonged,
thorough, and systematic work. No one can observe the work-
ing of the method without wishing for its introduction at home.

Another excellent custom in relation to the management of
hospitals, is that of making the visit between eight and nine
o'clock in the morning. M. Gosselin, the successor of Velpeau,
for instance, is always on hand at eight precisely, and calls

Letters to the Medical Record 83

the roll of the students with the exactitude of a drill sergeant.
Woe betide him who has overslept himself, and who, in spite of a
breakf astless race through the quarter, arrives after the feuille de
presence has been laid upon the table by the inexorable chief.

"Why is this ulcer not dressed, sir?" demands the surgeon,
fixing the trembling externe with his bright black eyes.

" I, I — excuse me, I was late. I meant to do it after the visit."

"Attend to it immediately, and never tell me again that you
were late. That is no sort of reason for neglecting your duty.
You are not to be late."

All honor to men who, knowing their own duty, know also how
to keep others up to the mark. All shame, confusion, and per-
plexity to those who, careless, indulgent, or shiftless, permit
things to be left undone that ought to have been done — after the
fashion of all miserable sinners!

As M. Gosselin's clinique lasts three hours, his extreme
punctuality alone saves for the student the bulk of the day
intact, and able to be employed at lectures, dissections, libraries,
etc. After experiencing all the benefits of this system, I feel a
certain horror of that prevailing in New York, where the visit is
made at any time between twelve and three, subject to all sorts
of variations dependent upon the exigencies of the physician's
clientele or caprice.

Cases of Metrorrhagia

Two cases of metrorrhagia have formed for M. Gosselin the
themes of recent and interesting clinical lectures. In the first
case the haemorrhage had come on after a suppression of men-
struation during two months, and the question of spontaneous or
provoked abortion immediately suggested itself. M. Gosselin
recapitulated the circumstances of the diagnosis which led him to
rest finally upon this suggestion. The uterine orifice was neither
granulated nor occupied by a polypus. Neither cancerous nor
fibrous tumor could be discovered. Ballottement of the uterus
was somewhat painful. The body was sufficiently voluminous
to be felt in the hypogastrium ; the orifice sufficiently open to
permit the introduction of the index finger.

Under these circumstances, in spite of the affirmations of the
woman that such contingency was impossible (affirmations which,
as every practitioner knows, are precisely what create the delicacy

84 Mary Putnam Jacob!

and difficulty of the diagnosis), M. Gosselin did not hesitate to
pronounce for an abortion. Principally on account of the denial
of the patient, the inference was further drawn, that the abortion
was deliberate. The haemorrhage ceased spontaneously, shortly
after admission to the hospital, and the principal danger that
remained to fear, was that of a metritis, determined by the
instrument that had been employed. Hence, while active
treatment was superfluous, active surveillance was impera-
tively required.

The other case was much more serious, and was first men-
tioned in connection with the autopsy of its subject.

The patient had arrived in a state of exhaustion, too great to
admit of a precise examination, but complaining of an abundant
uterine haemorrhage. Small vegetations were discovered around
and within the os uteri, which, though apparently different from
the tumefaction of cancer, proved at the autopsy to be carcino-
matous, A hard tumor of some size was discovered behind and
above the vaginal cul-de-sac. M. Gosselin could not decide
satisfactorily to himself whether the body of the uterus was
simply inflamed, or the seat of a cancerous tumor.

The day after admission the patient was seized with a most
intensely acute peritonitis. The constipation was obstinate, and
presently accompanied by vomiting of matters that, though
destitute of stercoral odor, resembled the contents of the small
intestine. It was not the green liquid usually vomited in peri-
tonitis, nor that tinged with brown occasionally observed, but
distinctly brown, and characteristic of intestinal obstruction,
especially a strangulated hernia. No trace of hernia, however,
could be discovered, and the conclusion was arrived at, that
the obstruction was caused by intestinal adherences dependent
upon the peritonitis.

At the autopsy, adhesions between the intestines and uterus
were found in fact to be sufficiently extensive, and the intestines
were so agglomerated around the pelvic cavity, that separation
of the organs was attended with considerable difficulty. Behind
the uterus was a cavity as large as a man's fist, circumscribed by
the loops of intestine, by the uterus, and the abdominal walls,
and containing a quantity of faecal matter, poured out from the
intestine by three or four large openings.

Such openings constitute an unusual lesion under the circum-

Letters to the Medical Record 85

stances. According to M. Gosselin, the uterine cancroid, which
extended from the neck into the body of the womb, had been the
point of departure of the whole train of circumstances. The
irritation of this tumor had first developed the effusion of plastic
lymph between the uterus and the intestines, which united
these organs by the firm adhesions noticed above. Extension of
this subacute inflammation had gradually thinned the coats of
the intestine, until, at a given moment, the internal tunic gave
way, and the contents were poured into the pelvis, exciting the
acute peritonitis which had carried off the patient. The in-
creased obstruction, upon which depended the stercoraceous
vomiting, was evidentl3^ as had been supposed, the result
of the rapid formation of lymph during the period of acute
inflammation.

Empyema and its Treatment by Perpetual Drainage.

An extremely valuable clinique was that held by M. Gosselin
on a case of empyema, that he had had under his eyes for two
years, and in relation to which he suggested several ideas that are
not everywhere current.

Until recently (observed the Professor) suppuration of the
pleura was regarded as a necessarily fatal disease, both on account
of the exhaustion induced by the long continued drain on the
system, as also by the habitual coexistence of grave pulmonary
disease. No cure is possible unless on the condition of entirely
evacuating the pleural cavity, which can only be effected spon-
taneously by the establishment of a bronchial or cutaneous fistula.
In a few cases children have been known to recover after the
establishment of the first kind of fistula, or vomica, as it is techni-
cally called, but only uncertain reliance can be placed upon the
benignity of this mode of evacuation, and no physician has the
right to provoke it. On the other hand, the cutaneous fistula is
even more dangerous, air insinuates itself into the cavity, decom-
poses the pus, and prevents the dilatation of the lungs, which
gradually assume a state of definite collapse. Hectic fever sets in
with all its train of symptoms, cough, diarrhoea, and ever5^hing
indicating the absorption of purulent matters, and the patient is
generally carried off in two or three months at the furthest.
Modem surgery, however, has ventured to interpose the oper-
ation of thoracentesis as an attempt to arrest the fatal march of

86 Mary Putnam Jacobi

this serious disease. This operation, whether performed by
simple puncture or by incision, is (according to GosseHn) essen-
tially the same, and essentially useless unless accompanied by a
certain precaution presently to be described. In the first case
the little wound speedily cicatrizes, and a repetition of tappings,
is required, which finally results in the establishment of a fistula.
By this the pus indeed escapes, but the air also enters, with the
consequences above described. The same thing is true of an
incision, and although there was more chance of success after
Sedillot suggested counter-openings, and the use of injections to
wash out the cavity, the results were still far from satisfactory.
M, Chassaignac, however, has had the happy idea of inserting
by the two openings perforated caoutchouc drainage tubes,
which afford free and continual exit to the pus, and thus neutralize
any evil effects resulting from the inevitable ingress of air. For
the pus, however decomposed, is innoxious if able to freely escape,
instead of being shut up in a close cavity, and stimulating its own
absorption.

In addition to the use of drainage tubes, injections of warm
water are made every two or three days. The patient who fur-
nished the occasion for these remarks, had been treated by the
method above described, which had proved remarkably successful.
He had first come under the care of M. Gosselin two years ago at
La Pitie, and appeared then in a dying condition, exhausted
by a long standing empyema and thoracic fistula. As soon as
free exit was afforded to the pus, and the drainage tube estab-
lished, the hectic fever began to mend, the patient's strength
rallied, and in three months the convalescence seemed so solidly
established, that the drainage tube was removed, and the man
left the hospital. The flow of purulent liquid had entirely ceased.
After working for about three months the patient began a second
time to suffer from oppression. A fistula reopened, and after
some weeks the general health had fallen to nearly as desperate
a condition as on the first occasion. Readmitted to La Pitie, and
treated again by a drainage tube, the patient again rapidly
recovered. After this experience, the tube was left permanently
in place. A third time he had run down in strength, and entered
La Charite, but was speedily built up again by the same treat-
ment, and thoracic injections of iodine and of sulphite of soda.
It was M. Gosselin's intention to leave the drainage tube in place

Letters to the Medical Record 87

until the pleural cavity should be entirely obliterated. And this
practice, and the theory upon which it is founded, constitutes the
original part of his lecture. He declares that it is absurd and
chimerical to hope that a serous membrane that has undergone
a pyogenic transformation, can ever regain its original character
or functions. So long, therefore, as it exists, so long will there be
drainage from renewed secretion of pus. But by prolonged
care in carrying off the corroding secretion as it forms, the sur-
geon may hope for the formation of adhesions which shall
definitely obliterate the cavity, and constitute the cure of the
disease.

By means of these combined methods, therefore, judiciously
applied, many patients, in even grave stages of hectic fever, may
be snatched from the jaws of death, and restored to a tolerable
degree of health. This, of course, cannot be expected if the
empyema complicates advanced tuberculous disease.

M. Gosselin also applies the system of perpetual drainage to
abscesses situated under the great pectoral, and whose evacuation
is rendered difficult by the tonicity of the muscle. A case of this
kind, actually in the ward, is doing extremely well. The tube, of
course, passes through the original and the counter incision.
Injections are made every two days with warm water.

Psoas-Iliac Abscess.

A very different kind of abscess was that presented by a case
admitted January 7th. This was a young woman, of rather lym-
phatic temperament, who had suffered for six months with pain in
the sacrum, and, for a month in addition with pain in the left groin.
In complete repose the patient was conscious of no suffering, but
the least movement awakened the pains, as also pressure in the
affected regions. Lying on her back, the patient was unable to
completely extend the left thigh, and forced flexion of the limb
was painful ; when the patient attempted herself to flex the thigh
on the abdomen, the lumbar vertebrae arched forward. This
same forward projection of the lumbar part of the spine was very
evident in walking, when also the patient limped, and rested
principally on the right leg. You will recognize this curvature as
a symptom of insufficiency of action on the part of the psoas
muscle. It would seem to be an instinctive attempt, by bringing
the fixed insertions of this principal flexor of the thigh in a direc-

88 Mary Putnam Jacobi

tion approaching a perpendicular to the lesser trochanter, to
supplement the intrinsic deficiency of power by the more favor-
able direction in which it was enabled to act.

Still another sign was obtained by placing the patient on the
abdomen, and after seizure of the ankle, bringing alternately
the right and left limb into forced extension. The left offered
a resistance altogether abnormal. Finally, deep pressure in the
groin, just above Poupart's ligament, detected an obscure tume-
faction, though not fluctuation.

In forming the diagnosis, M. Gosselin first set aside the possi-
bility of lumbago, which would have tormented the patient even
during repose, and been probably accompanied by rheumatism
elsewhere; and of uterine disease, indicated by no other symp-
toms; and arrived at the discussion of some different forms of
spinal disease. The pain in the sacrum must in fact be referred
to an ax rection of the spinal cord itself, of its membranes, or of its
bony casement. In the first two cases, however, the sensibility
or mobility of the limbs could hardly fail to be affected while the
patient in question offered no sign of lesion of either. There
remained, therefore, only arthritis of the sacral vertebras, which
tended to terminate in suppuration, if that were not already
commenced.

On the other hand, unquestionable symptoms (recapitulated
above) indicated inflammation in the neighborhood of the psoas
muscle. The possibility of simple chronic psoitis, or inflam-
mation of the surrounding cellular tissue, was eliminated on
account of its extreme rarity, except as a consequence of puer-
peral inflammation. There remained, therefore, after combin-
ation of all the facts, the conclusion of a psoas-iliac abscess by
congestion, resulting from caries of the Itunbar or sacral
vertebrae.

The prognosis (pursued the Professor) is excessively grave,
and contrasts strikingly with the apparent benignity of the dis-
ease at the present moment. Sooner or later, the abscess will
probably open, and the patient succumb to exhaustion from the
discharge. The only chance is that derived from the use of ton-
ics, and the local application of iodine with the faint hope that
the contents of the abscess may be absorbed. Even in that case
the spinal disease would continually tend to occasion the form-
ation of another.

Letters to the Medical Record 89

Danger of Apparatus in some Cases of Fracture of Jaw.

Three different cases of fracture, one of the lower maxilla, one
of the fibula, and one of the radius, furnished the occasion for
some pointed and suggestive remarks. The first case was the
result of a kick received on the jaw, and the fracture, though
distinctly indicated by crepitation, was accompanied by but
slight displacement, and an insignificant wound of the mucous
membrane. The accident was therefore slight in reality, but
Gosselin pointed out a certain possibility of grave danger from
an unlooked-for source. He declared that whenever, as in this
case, a solution of continuity had been effected inside the mouth,
the application of any apparatus for holding in place the frag-
ments of the jaw-bone w^s extremely mischievous. In two cases
observed at La Pitie, irritation of these machines induced exten-
sive inflammation of the mucous and submucous tissue,
ultimately reaching the bone, and exciting osteitis, followed by
denudation, necrosis, purulent absorption and infection, and
death. Even where death is not the result, the necrosis compels
an elimination which often lasts four or five months.

In view of these possible perils (upon which, says Gosselin,
authors have not sufficiently insisted), all apparatus should be
proscribed, and the fragments retained in place by a simple
bandage. The slight deformity resulting from lack of perfectly
accurate adjustment, is more than compensated by the security
for the life of the patient.

Treatment of Fracture of the Radius, etc.

Similarly, was an unexpected complication indicated as the
occasional result of an accident so simple and seemingly harmless
as fracture of the radius. The danger is again due to want
of care in the application of the apparatus. A patient comes to
the consultations the first day of the accident to have the bone
"set" and arm splints adjusted, and insists on returning home,
where he will be withdrawn from surveillance. The second or
third day the arm swells and becomes so intensely tightened by
the splints that, if they be not removed, the inflammation may
result in gangrene. Gosselin had seen some examples of this
consequence.

In the case in question, when the patient returned to the
hospital, after suffering for two days with sharp lancinating pains

90 Mary Putnam Jacobi

and sense of constriction in the arm, the limb was found greatly

swollen, and a bright red streak on the back indicated the ap-
proach of gangrene. This was happily warded off by the removal
of the splints, but the danger had been imminent.

It is, therefore, a rule with M. Gosselin, in all cases of fracture
of the arm, especially with female patients, children, or old people,
to wait during four or five days after the accident for the appli-
cation of the splints. During this time the part is kept con-
stantly poulticed, and at the end the inflammation is found to be
well reduced, and no difficulty opposes itself to the setting and
adjustment of the fragments, as the callus has still hardly begun
to be formed.

For further precaution, such an apparatus is selected as shall
leave the limb open to observation. Tampons of cotton, wool,
and then stout rolled compresses are placed against the free
ends of bone to press them into place ; a splint is adjusted to the
posterior and anterior face of the arm, and retained by two or
three bands of diachylon.

In the case of fracture of the fibula and external malleolus, the
leg was placed, after adjustments of the fragments, in a simple
plaster casing, formed of bands of tarletan, dipped in liquid plas-
ter. This was chosen because it alone becomes fixed in a few
minutes, while dextrined, gelatinized, or silicated bands require
some time to attain the necessary rigidity. Where, therefore,
the fracture only involves a small bone, as in this case, and there
is less dread from the possible breaking of the case, M. Gossdin
thinks that plaster is preferable to all other material for immobility.

Dangers of Erosions of Urinary Passages in Cases of Retention
— Reab sorption of the Retained Urine — Uraemia.

The case of a man who died shortly after admission to the
hospital for a retention of urine caused by urethral stricture,
furnished opportunity for an acute suggestion from the lecturer.
During life, the sinister progress of the disease had been sus-
pected to depend upon concealed inflammation of the kidneys,
possibly an abscess, whose presence was betrayed only by the
purulent infarction which proved fatal. But at the autopsy,
the kidneys were found to be perfectly healthy, and some small
erosions of the urethra and the bladder were the only lesions
discovered to explain the death.

Letters to the Medical Record 91

These lesions, however, were not sufficiently extensive to
have caused death directly, but their indirect agency might be
explained in one of two ways. It might be supposed that one
or both kidneys had ceased to secrete, their functions being
interrupted by sympathy with the interruption of the excretion.
In this case, death would result from intoxication, caused by
accumulation of urea in the blood. But the patient had exhibited
no signs of coma, nor the fever characteristic of ordinary ureemic
intoxication. M. Gosselin inclined to adopt the other theory,
which suggested reabsorption of the retained urine, at the eroded
surfaces of the urethra and bladder. A special uraemia would
therefore result, betrayed by somewhat anomalous sjmptoms,
but leading to definitely fatal results as that dependent upon
suppression of urine.

M. Gosselin explained that his reason for insisting upon this
mode of fatal termination, was to point out the danger of even
small erosions of the urinary passages, in cases of retention of
urine from any cause. With the possibility of this danger in
mind, the surgeon would often be much more careful than at
present, to avoid tearing the mucous membrane by any instru-
ment employed in treatment.

Diagnosis of Cancerous Stricture of Rectum.

Nearly at the same time, a patient died with stricture of the
rectum, and in exposing the result of the autopsy, M. Gosselin
recapitulated the clinical details of the case. The patient had
entered the wards only eight days previous to his death, and at
that time the stricture was so narrow that the little finger of the
surgeon could hardly penetrate into the rectum across it. Below
the stricture the finger perceived a rough mammillated surface,
and the tissues around the narrowing were extremely hard and
resistant. These circumstances, joined to the profound emaci-
ation and exhaustion of the patient, excited some suspicion of
cancer. But it is rare that cancer is equally disseminated over all
the surface of the rectum, or produces a stricture so narrow or so
near the sphincter. Cancerous stricture is never impassable to
the finger, as was the lesion in question. Moreover, a cancer
would not have remained rigid so long a time, but ulcerated
considerably before the five years that had elapsed since the
beginning of this one.

92 Mary Putnam Jacob!

Cancer being eliminated, the diagnosis turned upon fibrous
thickening, probably of course under the influence of syphilis.

An operation was decided upon, and two or three incisions
were made at the level of the stricture. Before the operation,
however, the patient had been attacked with a chill and some
fever, both of which returned with renewed intensity afterwards,
and death occurred in consequence of purulent infarction. A
metastatic abscess was found in the lungs.

Locally, the autopsy revealed an abrupt stricture, caused by
hypertrophy of fibrous tissue, and accompanied above its upper
border by a large shallow ulceration of the mucous membrane of
the rectum. A certain amount of pus covered the surface de-
nuded of epithelium. This ulcer, said the Professor, added
greatly to the gravity of the disease, determining the tenesmic
diarrhoea which had exhausted the patient, and probably con-
stituted the immediate cause of death.

P. C. M.

The Catalogue of the U. S. Army Medical Museum, and a
Foreigner's Estimate of the Medical Resources of Amer-
ica— ^Two Interesting Cases of Ovariotomy — The Use of
Drainage Tubes — Guerin's Pneumatic Occlusion.

Paris, February 9, 1868.
To the Editor of the Medical Record.

Sir — The Archives of Medicine, in a very complimentary
note, acknowledges the gift of the catalogue of the United States
Army Medical Museum.

Every one interested in the advancement of medicine and the amelioration
of the health of armies, ought to feel indebted to the American Government for
the gigantic and costly enterprise which it has just undertaken. The magnifi-
cent volume which has been sent us by the liberality of the Surgeon -General
cannot fail to be of immense utility, even to us to whom the rich Museum
is inaccessible. Thanks to the summary observations which it contains of
each piece registered in the Museum, we are able, in a great measure, to study
the collection as if it were under our eyes, and shall in the future have the means
of controlling the quotations of American surgeons who shall take their illus-
trations from the Museum.

Our administration is not accustomed to such generous initiative in the
distribution of official reports to the journals. It has been necessary for the
American Goverrunent to have the honor of giving the example, and of meet-
ing, with the most laudable munificence, the silent wishes of the medical press.

Letters to the Medical Record 93

A Foreigner's Estimate of the Medical Resources of America.

I met, the other day, a young Norwegian surgeon, with hair
as yellow and eyes as blue as became a countryman of the Viking
who had been spending some months in the study of this Mu-
seum, and expressed for it the most unqualified admiration. "I
cannot understand," he said, "why you Americans should take
the trouble to come to Paris to study surgery; your facilities at
home are worth fully as much, if not more, than all you can get
here."

Cases of Ovariotomy.

Certainly no one need come to Paris to study ovariotomy.
M. Richet, than whom a more distinguished surgeon is hardly
living, has just had the misfortune to add another to the list of
failures in this formidable, but sometimes successful operation.
He had undertaken the extirpation of the cyst, to comply with
the urgency of a brother physician, who considered the case
remarkably favorable. M. Richet, however, pronounced an
unfavorable prognosis, on account of a circumstance, which he
has been subsequently led to consider sufficiently characteristic
to serve as a formal contra-indication to an operation. The
abdomen of the patient was the seat of a fluctuating timior,
apparently a unilocular cyst ; but it had not the form which should
have been given by a cyst of so considerable size. Instead of
being prominent towards the middle, and advancing as it were in
a point, the belly was rather flattened, and much enlarged at the
sides, but not at all prominent in the middle. In the meantime
the surface was even, and no sign existed of a division of the cyst
into cavities; the unequal juxtaposition of whose walls might
explain the flattening of the abdomen.

M. Richet could not well account for this circumstance, but it
inspired him with an indefinable apprehension of evil conse-
quences, an apprehension only too well realized. For when, after
incision through the integuments and subperitoneal tissue, both
of which were thickened by adipose tissue and much infiltrated,
the surgeon arrived in the cavity of the peritoneum, the most
solid adhesions were discovered, uniting the cyst to the abdominal
walls. The first could be turned with the hand, but they pres-
ently became so solid as to resist all efforts. Convinced that
localized adhesive peritonitis and fibrinous adhesions were more

94 Mary Putnam Jacob!

readily formed in the pelvic cavity than towards the abdominal
walls, M. Richet inferred that the obstacles met with in this
latter locality would be re-encountered, and on even a more
formidable scale, towards the base of the tumor. He therefore
resolved to abandon the operation, and the incision was united
with a few metallic sutures.

The patient, however, died of peritonitis the next evening,
and the autopsy fully confirmed the prevision of M. Richet. The
cyst could only be separated from the abdominal wall by tearing
a part of this latter; and in the pelvic cavity the adhesions v/ere so
close, that a slow and careful dissection was required to remove
them. The bladder and uterus were involved with the tumor.
This had no pedicle, properly speaking; it was composed of a
principal cavity, from whose wall were suspended, floating,
several smaller cysts; it was nourished by means of its intimate
and extensive adhesions, especially with the uterus. It is certain
that the continuance of the operation would have been com-
pletely impossible, since the isolation of the cyst was so difficult,
even on the cadaver.

The remarkable flattening of the abdomen was therefore
accounted for b}'- the very solid adhesions which maintained it
solidly fixed, and drawn downwards. In such cases, concludes
M. Richet, ovariotomy should never be attempted.

It is interesting to notice also, that in spite of the repeated
attacks of peritonitis which must have occurred to produce the
adhesions, the patient had never suffered any abdominal pain, a
fact which had greatly conduced to excite the false hopes for the
success of the operation.

From Strasbourg, however, comes a note of better cheer. M.
Koeberle has succeeded in saving a patient operated upon for an
ovarian cyst, and that in spite of the most formidable
complications.

The patient was 43 years old, the mother of three children,
and endowed with a vigorous constitution. She was affected
with a mu'tilocular cyst of the right ovary, of which one of the
subdivisions had ruptured eight months previous to the operation,
and occasioned a grave peritonitis. From that time had set in
ascites, emaciation, anaemia, and hectic fever. Towards the end
of September tapping was performed, and about six litres of
brownish liquid, partly serous and partly stringy, were with-

Letters to the Medical Record 95

drawn. After this the general health of the patient was notably
ameliorated. Ovariotomy was practised on the 26th of Novem-
ber, under the influence of chloroform. An incision was made,
twenty-five centimetres in length, giving issue to three litres
of reddish serum. Puncture successively of three divisions
of the cyst, of which one furnished a yellowish, one a brown, and
one a grayish liquid, altogether amounting to eight litres. There
remained a multilocular mass, weighing two kilogrammes, which
was easily removed after division of a few adhesions, which
united it to the omentum and abdominal wall. The former
adhesion, which contained large vessels, was destroyed with the
actual cautery. The pedicle of the tumor, four centimetres
long, was divided by a wire loop, by means of a slip knot. The
abdominal cavity was well sponged out, and the incision united
by means of four deep, and six superficial sutures. A glass tube,
ten centimetres long, plunging in the pelvic cavity along the posterior
wall of the uterus, was placed in the lower angle of the wound, to
admit of a free escape of the ligtiids. The operation lasted three
quarters of an hour. About 400 grammes of blood were lost.

A pelvi-peritonitis occurred, which remained localized and
disappeared rapidly under the influence of the free escape afforded
to the liquids, and the half sitting position given to the patient.
But the fourth and fifth day the patient became restless, and the
pulse counted 130. On the sixth day the sleep was interrupted
at two in the morning, the restlessness augmented to agitation
and anxiety; the pulse, still at 130, became variable small, and
irregular; inspirations thirty-six; sweats, coated tongue, diminu-
tion of the urine, and tympanitis of the abdomen, all announced
grave change for the worse.

By the 7th the condition of the patient was extremely menac-
ing. At five o'clock in the afternoon, the surgeon discovered
dulness in the right flank, between the iliac crest and the hypo-
chondrium, extending over a space about as large as the palm
of the hand. There was evidently a collection of serum, formed
during the last fifteen hours, and dependent upon a local peri-
tonitis (probably connected with inflammation of the ovarian
vessels), and which would not delay to become general. Bold
measures were necessary, and on the spot, M. Koeberle made an
incision in the centre of the dulness, about seven centimetres
above the iliac crest. The patient was too feeble to be chloro-

96 Mary Putnam Jacobi

formized, so recourse was had to a local apparatus for the vapori-
zation of ether, which sensibly diminished both the pain and the
haemorrhage. After division of the tissues to the depth of six
to seven centimetres, the peritoneum was discovered, and being
opened, gave issue to about 150 grammes of reddish serum.
This was completely withdrawn by means of a canula, the exterior
wound united by a single suture, and a tress of lint, replaced
subsequently by a glass tube, served to maintain external communi-
cation with the cavity of the peritoneum. The local dulness had
disappeared. The patient was placed in a half-sitting position
and in a lateral decubitus towards the right side, in order to
facilitate the escape of the liquids.

The next day, the patient, who had been in a subcomatose
condition exhibited a marked improvement. The pulse was
between 118 and 125, and the respiration twenty-two. On the
fourth day after the incision, the borders of the wound were
invaded by an erysipelas, which extended about twelve centi-
metres. Treated with tincture of iodine on the limits of the
inflamed parts, the erysipelas was arrested on its third day.

The third crisis attended or consisted in the evacuation by the
rectum of gray purulent stools. The patient afterwards became
more comfortable, but the tumefaction in the right flank re-
appeared, and continued, and the surgeon was unable to reach it
by sounds introduced, into the wound. Finally, on the eight-
eenth day after the original operation, the purulent collection
opened spontaneously by means of the large tube which had
been left in the wound ; and a great quantity of pus escaped, and
the flow continued during two or three days. The tumefaction
diminished in proportion, and disappeared entirely. The tube
was gradually shortenejd, and at the end of a fortnight the cicatriz-
ation of the iliac wound was complete, as well as that on the
median line, made for the extirpation of the cysts, and where a
tube had constantly remained. In a month and a half after the
operation, the health of the patient was perfect.

The striking peculiarities of this remarkable case unquestion-
ably belong to the successful plan of leaving the drainage tubes in
communication with the peritoneum; and to the boldness which
risked an incision of that membrane, to give issue to the products
of a local peritonitis. General peritonitis was thus warded off,
three distinct times — first, in connection with the original oper-

Letters to the Medical Record 97

ation, then at the moment of the subsequent tumefaction, and
finally during the formation of the abscess. M. Koeberle
remarks, that when in the course of peritonitis a collection of
liquids has been formed, opening of the peritoneal cavity is far
from presenting the same gravity as when the membrane is
healthy. The pseudo-membranes which agglutinate together the
intestines, have rendered possible the formation of circumscribed
cavities in which the exuded liquids have been able to accumu-
late, and these serous or purulent foci may be opened, without
interesting the remainder of the peritoneal cavity. When these
liquids, which have a great tendency to decompose and become
fetid, have been evacuated, there is nothing to prevent washing
out the cavity with injections of sulphate of soda or of phenic
acid. By this means, the affection is reduced to a simple local
peritonitis.

M. Koeberle has performed nine ovariotomies during the last
six months, and only lost one patient, and she was fifty years old,
and had submitted eight times to paracentesis.

The Benefits of the Drainage Tubes,

The immense advantage to be derived from the practise of
leaving a tube inserted in a cyst, to provide for the complete
evacuation of its contents, is shown in a remarkable case of
hydatid of the liver, cited by the Archives from an observation of
Dr. John Harley.

When the patient first consulted the physician, he was
affected with an abdominal tumor of four years' duration, con-
tinuous with the liver in the hypochondrium, and extending
to within two fingers' breadth of the pubes and Poupart's liga-
ment. Dulness extended from this point to the level of the right
nipple. On percussion, fluctuation was evident in all parts of
the ttmior.

Three times in the course of the first eighteen months of the
development of the tumor, the patient had suffered attacks
of sharp pain in the abdomen and epigastrium, of which the first
attack had lasted twenty -four hours, and the last fifteen days.
He had never been jaundiced.

From the seat of the tumor and its development, Dr. Harley
diagnosticated an hydatid cyst of the liver. No treatment, was
instituted. Two years later the patient retiixned, with the tumor

98 Mary Putnam Jacobi

somewhat increased in size. The girth measured forty-two and
five-eighths inches, and under the influence of a sHght attack of
local peritonitis, the cyst increased so rapidly, that in ten days
the measure of the girth had increased to forty-four and a half
inches. In view of this rapid development, it was decided to
tap the cyst, which was done on the level of a line going from
the xiphoid cartilage to the umbilicus. A clear colorless liquid
escaped, whose complete evacuation occupied two hours. Eleven
litres of this liquid were collected, and found to contain several
broken cysts, the size of a filbert, and cysts unbroken, as large
as a pea. The operation was well supported, and relieved the
patient. The abdomen retracted, and by palpation, below the
umbilicus, could be perceived the lower border of the cyst.
The canula was left in place.

The patient remained without fever till the eighth day, when
the canula escaped from the wound, and all flow of liquid ceased
during twelve hours. The cyst became distended and per-
ceptible in both hypochondria, the skin hot, pulse 120. The
canula was replaced, and immediately there escaped 250 grammes
of a turbid liquid, dark yellow in color, and with a fetid odor.
The febrile symptoms disappeared, while the flow was only
interrupted by the fragments of hydatid cysts that from time to
time blocked up the canula. When the obstruction became
definite, the cyst was distended a second time, and grew painful,
and the fever returned. On this occasion, an elastic sound, nine
inches long was introduced into the cavity by the canula, and
600 grammes of liquid were collected. About the same amount
escaped during the course of the following fortnight, and occa-
sionally, owing apparently to the rupture of some secondary cyst,
the flow would become more abundant.

The forty-third day the canula was entirely removed, but the
elastic sound left in place. Up to this date injections had been
made of water mixed with iodine or creasote, forty drops to a litre.
On the fifty-first day, a considerable haemorrhage was produced in
the cyst. The pulse immediately mounted from 96 to 140, and
in the evening was 160. The skin became hot, dry, and yellow-
ish, the cyst hard and distending the epigastrium and hypo-
chondria, and the patient vomited repeatedly. 500 grammes of
thick fetid sanguinolent liquid, resembling the blood which flows
after the section of the liver, were withdrawn from the cyst.

Letters to the Medical Record 99

which was then carefully washed out with water, containing some
creasote. During the following week, the iodine injection was
replaced by a solution of twenty-five to fifty centigrammes of
nitrate of silver, in some ounces of water ; afterwards an injection
was made every morning and evening of a solution of four
grammes of sulphate of zinc in 300 grammes of creasotized
water.

After several days, during which the stools were quite color-
less, there was suddenly evacuated by the rectum a quantity of
pultaceous matter, of a color analogous to that of the liquid
coming from the cyst. A few days later, a great quantity of pure
bile flowed from the wound, fifteen grammes being collected
in some minutes. Communication was therefore evidently
established, on the one hand with the intestine, on the other with
the gall bladder. This was the fifty-third day.

After various less important vicissitudes, it is noticed on the
123d day, that no more bile escaped from the wound, that the
cyst was greatly diminished in size, so that the sound, which had
penetrated 9 and 10 inches, now extended only 4. On the 148th
day, the flow had ceased, and the sound was withdrawn. Shortly
afterward, the health of the patient being entirely re-established,
he resumed his ordinary occupations. The girth had diminished
13 inches. The dulness of the liver was normal, but the spleen
remained hypertrophied. The heart had resumed its proper
position. No trace remained of the tumor.

Dr. Harley follows the recital of this interesting case with
some general remarks on the treatment of hydatid cysts, in which
he particularly insists on the necessity for favoring the complete
evacuation of the cavity. He thinks that nearly all failures are
due to neglect of this precaution and of any attempt to obliterate
the hydatic membranes. If any liquid be left, it is sure to putrefy
sooner or later, and infect the blood. Then follows a synoptical
table of about 100 cases gathered from different authors. In
thirty -four, a single opening had been made, followed by complete
or partial evacuations of the liquid and immediate closure of the
wound. There were eleven cures, thirteen ameliorations, and
ten deaths.

In the second table are thirteen cases treated by successive
openings, with or without iodine injections; eight ameliorations,
two cases without result, and three deaths.

100 Mary Putnam Jacobi

In the third table, containing thirty cases treated by one or
several openings followed by prolonged communication with the
exterior, there are twenty-three cures, of which at least eighteen
may be considered radical, and only seven deaths, five of which
must be attributed to a new accumulation of liquids which had
been unable to escape, and had putrefied. In ten cases in which
the tumor was opened by caustic potassa, were observed three
cures, three ameliorations, and four deaths. Dr. Harley thinks,
moreover, that the caustic presents no real advantage, and has
the disadvantage of being much more painful than the other
treatment.

These results therefore tend to confirm the views expressed in
connection with the operation for ovarian cysts, namely that
the dangers do not depend upon the admission of air into, but the
imprisonment of liquids within the cavities, natural or artificial.
Escape, escape, escape for all these vile and noxious fluids — such
is the watchword of a host of modern surgeons, in a host of cases,
and the doctrine is perhaps best applied by M. Maisonneuve, in
his apparatus that fulfils at once the double purpose of occlusion
of the wound, and aspiration of the liquids at its surface or bur-
rowing in its recesses. I believe I have already described to you
this apparatus, or at all events it is well known to you, if only for
the reason that every American physician who comes to Paris
goes straight to the Hotel Dieu, to see it in operation.

M. Gosselin, at La Charite, carries out the principle of free
drainage for other purposes than that of preventing purulent
infection. In case of cold and burrowing abscesses, with or
without fistulas, he generally inserts a small perforated drainage
tube by the original opening, at the same time exercising steady
pressure upon the dilated walls of the cavity. In this way he has
recently treated with marked success a case of indolent abscess
burrowing under the great pectoral muscle, and has now under
treatment an abscess at the malleolus, and another resulting
from axillary adenitis; a case of rather diffused phlegmon of the
neck was similarly treated, but succumbed to the erysipelas
which had been imminent from the first day of the disease, much
more before the insertion of the drainage tube. This instrument
does not in any case seem to provoke superficial irritation around
the wound, and what deep-seated irritation may be excited by
the pressure of even such a mild foreign body as gutta-percha,

Letters to the Medical Record loi

does not seem to pass beyond what is advantageous for stimulat-
ing the reparative powers of the secreting surfaces.

Guerin's System of Pneumatic Occlusion.

In a recent seance at the Academy of Sciences, M. Guerin
gave a resume of the applications hitherto made of his system of
pneumatic occlusion, — essentially the same as that of Maison-
neuve to which I have just alluded. He ranks these applications
under four categories.

1st. Wounds and simple surgical operations such as incisions,
ablations of cicatrices or of subcutaneous tumors, extractions of
foreign bodies from articulations.

2d. Grave operations, such as amputations of limbs, and
accidental wounds of the same importance.

3d. Contused wounds, openings of the skin, and simple com-
plicated fractures, that is with perforation of the skin, while the
bones are simply broken.

4th. Wounds from fire-arms with dilacerations and destruc-
tion of the tissues, fractures with crushing of the bones, and
wounds uniting the gravest complications of traumatic lesions.

In the most favorable condition, the pneumatic occlusion pro-
duces cicatrization without traumatic fever, and without sup-
purative inflammation; that is to say, it realizes union by first
intention.

In less favorable cases, and when the wound has already been
a long time exposed, or contains foreign bodies, or, finally, is
complicated with anterior morbid conditions, pneiunatic occlu-
sion cannot prevent a certain degree of suppurative inflammation;
but in virtue of the continuous aspiration which it exercises, it
opposes all accident resulting from the putrefaction and absorp-
tion of altered fluids, and in all cases favors, and renders much
more rapid, the cicatrization, and consecutive organization of
wounds.

P. C. M.

The Treatment of Abscess of the Liver by External Incision —
Swallowing of a Fork — Perforation of the Stomach and Colon;
Escape of Instrument through an Abscess in the Abdominal
Walls — Treatment of Morbus Coxariusfrom a French point of
view.

102 Mary Putnam Jacobi

Difficulties in Childbirth with an Abnormal Pelvis; Interesting
Suggestion relative thereto — Cases of Complicated Rheumatism
— Nux Vomica i?t the Dyspepsia of Hypochondriacs — 5m/-
phide of Carbon as a Local Ancesthetic — Dextrine in Varicose
Eczema.

To the Editor of the Medical Record.

Sir — The medical experience of any particular country on the
diseases peculiar to the locality, serves somewhat as Professor
Tyndal's lecture apparatus, which projects upon a screen the
magnified representation of operations too delicate to be other-
wise perceived by the audience ; for the characteristics of maladies
that may be inadequately appreciated when observed only at
rare intervals, become salient and striking when a nimiber of
similar cases are massed together. Hence it is in the study of
such masses of facts, that the practitioner becomes able to cope in
his own climate with the exceptional cases of disease, for which,
however infrequently, he is bound to be prepared.

Abcess of the Liver, etc.

Abscess of the liver, as every one knows, is as common in
warm countries as it is rare in our temperate zone. The Medico-
Surgical Society of Alexandria (Egypt), has just published
the conclusions of a most interesting discussion on the treatment
of this formidable degree of hepatic inflammation — conclusions
that it cannot be uninteresting to relate to you.

The turning point in the debate, was the question of the
utility of puncturing the abscess, and a great number of cases
were reported by different members of the Society, in which
the effects of the operation could be compared with the march
of the disease when treated less energetically. I give you the
sum-total of the results, without entering into the details.

The cases may be divided into two groups, the first comprising
the abscesses not operated upon, the second, those upon whom
the operation was performed. Each group is again subdivided
into abscesses the size of a man's fist, called large, and all below
this dimension, classed as small.

The first group, abscesses not operated, contains 8i cases,
among which there were 58 deaths, 14 cures, and 9 doubtful cases.
The mortality was, therefore, 80.55 P^^ cent., the recovery 19.45.

Letters to the Medical Record 103

In the second group are 42 cases, of which were 21 deaths and
21 recoveries — mortality 50 per cent., recovery the same. The
first subdivision of the first class, in which the abscesses were as
large as a fist, or larger, contained 24 cases, with 21 deaths, and 3
recoveries — mortality 87.50 per cent., recovery 12.50.

The second subdivision of this group (abscesses smaller than
a fist) comprised 13 cases, of which 9 died, and 4 recovered —
mortality 69.23 per cent., recovery 30.76.

In the first subdivision of the second group (large operated
abscesses), are 22 cases, 15 deaths, and 7 cures — mortality 68.18
per cent., cures 31.81,

In the second sub-class (small abscesses), are 10 cases, of
which 3 died, and 7 recovered — mortality 30 per cent., cure 70
per cent.

It is noticeable that each group contains a number of cases
in which the size of the abscess had not been determined with
sufficient precision to rank it in either of the sub-classes. In view
of these statistics, it was resolved by the Society that, 1st, in all
cases of hepatic abscess, large or small, the chances for recovery
are considerably greater if an operation be performed; 2d, that
in cases of small abscesses the operation is so favorable that
more than two-thirds of the patients are cured.

Among the 14 cases unoperated upon, in which the patients
recovered, in 1 1 the abscess opened spontaneously into the lungs.
In two cases, the communication was effected with the intestine,
and in one, with the stomach. But generally, whenever the
abscess opened anywhere than into the lungs, the rupture proved
fatal. This was the case 14 times, where the rupture occurred
three times into the peritoneum, four times into the intestine,
four times the pleura, once the stomach, once the pericardium,
and once the locality is not specified.

Death in all cases, whether following an operation, or occur-
ring by the natural progress of the disease, was determined
either by general hectic fever, or by uncontrollable diarrhoea.
The latter was the most frequent cause of death after an un-
successful operation, and generally occurred when the puncture
had been delayed to an advanced period of the disease. It was
indeed decided by the Society that the operation should be per-
formed as soon as possible after recognition of the abscess, and an
exploration made, even when the liver was scarcely painful and no

104 Mary Putnam Jacobi

fluctuation could be distinctly perceived. In default of the most
salient symptoms, an experienced observer would almost always
pronounce upon the existence of an abscess by the earthy tint
of the complexion, accompanied by augmentation of the size of
the liver; an extremely obstinate diarrhoea, yielding to no treat-
ment; nocturnal sweats; often periodical fever, chills, and loss
of appetite. It is affirmed that the introduction of the explor-
ing trocar, even if the liver be healthy, is not followed by any
serious accident.

It was generally agreed that the use of caustic was to be
proscribed, as being slow, extremely painful, and possessing no
advantages over the bistoury. For the adhesive inflammation
desired by the employment of the caustic, is invariably set up
around the drainage tube, within 24 hours after puncture by the
bistoury.

It was asserted, moreover, that the action of the caustic
is not well circumscribed, but is apt to occasion badly suppurating
wounds.

The persistence of the drainage tube is a most important
element of the treatment. This tube is liable from time to time
to become blocked up, in which case it may be withdrawn, cleaned
out, and replaced.

Swallowing of a Fork, perforation of Stomach and escape through
abdominal walls.

A most remarkable case of traumatic abscess is reported in the
Medical Gazette of Strasburg, as occurring in an insane asyltmi at
Zutphen. The patient was a w^oman 64 years old, affected with
lypemania, who had swallowed a silver fork for the purpose of
committing suicide. She was received into the asylum two days
after accomplishing this feat, and the physician had no difficulty
in detecting the foreign body in the stomach. The teeth of the
fork were in the cardiac portion, directed upwards and forwards,
the handle lying backwards, in the pyloric extremity. The
patient complained of no pain, only a sensation of weight and
oppression at the stomach. During the first days, she was sub-
mitted to entire repose, severe diet, and expectation. A slight
febrile reaction gradually established itself, and the patient
at last complained of pain in the left epigastric region. These
S5anptoms continued without aggravation during three months,

Letters to the Medical Record 105

and then gradually subsided. At this time the teeth of the fork
disappeared from the place where for so long they had been
plainly perceptible, and instead was discovered a singular tumor
in the abdomen, to the left of the timbilicus, which occasionally
had the air of a gravid uterus at four months. It was impossible
to decide upon the nature of the contents of this tumor, in which
no sign of the fork could be perceived. The pain was trifling, the
pulse at 72 ; stools easily obtained by enemata. A slight febrile
reaction occurred later, but the digestion always remained
undisturbed.

Five months later, the tumor, which till then had been
quite round, began to point. The abdominal walls were not
adherent. In the course of the following month an abscess
formed; the integuments gradually reddened and thinned, and
the tumor opened spontaneously, and gave issue, first, to a small
quantity of pus, then to liquid faecal matters. About a week
later, at the morning visit, the physician was surprised at per-
ceiving the four teeth of a fork behind the abdominal wall, close
by the fistulous opening. By prudent manipulation, it became
evident that the foreign body was only retained in place by the
integuments, and in effect, after a couple of lateral incisions, the
fork was easily extracted in the perpendicular direction that
it occupied to the abdominal wall. The handle was entirely
surrounded by extremely fetid faecal matters; a great number
of crystals of phosphate of lime covered the teeth of the
fork, which had turned black from a coating of sulphate of
silver.

The patient, who during the last days had suffered a good
deal of pain, was immediately relieved after extraction of the fork.
The fistula was simply dressed, and healed without difficulty, a
firm cicatrix being established by the end of a month. For some
time longer, the neighboring parts remained infiltrated, but even
this infiltration gradually disappeared, and the patient was
completely restored to health.

As the tumor had always remained on the left side of the
abdomen, it seemed evident that the fork had not traversed the
length of the intestinal tube, but passed directly from the stom-
ach into the transverse colon, after an adhesive inflammation had
established solid connection between the two organs. It was
inferred that the crystals of lime salt had been deposited on the

io6 Mary Putnam Jacobi

teeth which had arrived in the colon, while the handle still
remained in the stomach.

It is extremely remarkable that the general health was so
slightly deranged by the ten months' sojourn and peregrinations
of a foreign body in the stomach and intestines. Perhaps the
mental alienation of the patient may be presumed to have
blunted the general physical sensibilities, a circumstance fre-
quently observed in the pathology of the insane.

Treatment of Coxalgia from a French point of view.

M. Philipeaux, who has for some time made a sort of specialty
of coxalgia and its treatment, has recently published a memoir
upon resection of the head of the femur, in cases of this disease
that have resisted general treatment, and are conducting their
victims to the grave. 96 instances of this operation have been
published, since it was first practised by Antony White, of Lon-
don, in 1 821; and half the operations have resulted in radical
cures. Surgeons have objected to this operation on the ground
that it was unnecessary, since all curable coxalgias could be cured
by general treatment; that it was fruitless, since the cotyloid
cavity was always affected, as well as the head of the femur;
and that any attempt to operate upon this cavity was too danger-
ous, on account of its proximity to the pelvis. M. Philipeaux
admits the seriousness of all these objections, but, in reply to
the first, observes that the operation is only proposed as a last
resource, in cases where all others have failed; in answer to the
second he declares that the lesion of the cotyloid cavity has many
more chances to heal, if relieved of the irritation caused by the
presence of the diseased femur; and finally, although the danger
of applications to a point so near the pelvic cavity is not to be
dissimulated, yet the surgeon may in many cases be justified in
cauterizing, with circumspection, the acetabulum with the
actual cautery, and in all cases may remove the fungosities therein
developed. The resection is contra-indicated when pulmonary
phthisis, scrofula in the third degree, heart disease, or vertebral
caries, complicates the coxalgia. Too great an extent of the
local caries is also a contra-indication. The operation is
favorable in proportion to the youth of the patient; and the
following table of 67 cases shows clearly how success varies with
age:

Cures

Death

12

7

20

10

7

3

2

3

2

0

0

I

Letters to the Medical Record 107

Cases Age

19 5 to 9 years

30 10 to 19

10 20 to 29

5 30 to 39

2 40 to 49

1 50

Spontaneous luxation of the head of the femur is one of the
most favorable conditions for resection, but is not, as was at first
supposed, indispensable. In 32 cases operated, where this lux-
ation did not exist, are counted 16 cures, 9 deaths, and 7 doubtful
cases.

The operation comprehends three periods:

A . First Period. The patient is placed upon the sound side,
with the trunk slightly raised, and the lower limbs extended.
Aneesthesia, of course, is induced.

The surgeon, standing at the right of the patient, feels for the
upper border of the great trochanter, and by his incision describes
a semi-lunar flap, whose convexity is inferior. All parts bur-
rowed by fistulas should be included in the incision, and all parts
removed which seem incapable of assisting in the cicatrization.
The insertion of the trochanter muscles is divided, and the
border of the cotyloid cavity attained. When all the articu-
lation is carious, the capsule is swollen and often perforated.
If it be yet intact, the limb is placed in flexion and abduction
before dividing the capsule by a pointed bistoury. The mem-
brane is then loosened above and below by means of a bistoury
guarded by a button. In the majority of cases, the round
ligament no longer exists; when it does, it is to be cut with this
same instrument.

B. Second Period. Luxation. — Forced luxation should al-
ways precede section of the femur, except where the parts are
united by osseous stalactites. When the femur is intact it is
easy to use it as a lever, and execute with it movements of
adduction and inward rotation, which rapidly drive the head out
of the cotyloid cavity and the lips of the wound.

C. Third Period. Resection. — A small board is then placed
behind the dislocated head, the neck denuded of its periosteum
(of which as much as possible should be preserved), and then
severed by means of a straight or chain saw. If, on examin-
ation of the surface of section, any diseased bone is found to have

io8 Mary Putnam Jacob!

been left, it is removed by a second stroke of the saw, which
sometimes goes below the small trochanter. The great trochan-
ter should be removed in any case, says M. Philipeaux, following
Malgaigne, for if left, it will fit itself into the cotyloid cavity, and
so oppose the free issue of pus. Finally, all articular fungosities
should be removed, and if necessary, the acetabulum rasped,
gouged, or cauterized.

D. Consecutive Treatment. — After the operation is terminated
the patient is placed in dorsal decubitus, and the sound side of the
body somewhat elevated by means of oat cushions, so as to favor
the flow of liquids from the wound.

Mattressed gutters for the reception of the operated limb are
rejected as useless, fatiguing, and greatly interfering with the
dressing of the hip. M. Philipeaux prefers to simply support
the patient by the cushions. In two classes of cases, however,
it is necessary to maintain continued extension of the leg: ist,
when the surgeon has been unable to place the femur in complete
extension during the anaesthetic sleep. 2d, when, after a
spontaneous luxation, the head of the femur had mounted high
enough to occasion notable shortening, which persisted after the
operation.

The wound oniy requires simple treatment. The edges are
drawn together at the two angles by bands of diachylon, while
the middle is left open for the introduction of a few balls of lint.
The whole is then covered with anointed linen, and with com-
presses. This treatment may continue until the wound is filled
up with fleshy granulations. If the suppuration is abundant,
the wound should be washed two or three times a day with warm
aromatic injections ; if there be danger that it close too quickly, a
caoutchouc drainage tube is introduced.

Before cicatrization is complete, it is well to accustom the
limb to some slight movements, but only allowed gradually
and with much caution. These movements are renewed and
extended in different directions, so as to restore, if possible,
mobility to the joint. Excessive exercise, however, is hurtful,
as tending to produce too much laxity in the articulation.

In the two most recent cases of resection, the patients pre-
served the mobility of the femur, and recovered with a pseudo-
arthrosis instead of an anchylosis. In Mr. Le Fort's memoir on
the subject, twenty-seven patients are reported to have escaped

Letters to the Medical Record 109

with a perfectly useful articulation, and capable of walking very
tolerably, although more or less lame.

Permanent shortening of the limb is to be palliated, of course,
by a raised metallic sole to the foot.

DiflBlculties to Childbirth in Abnormal Narrowness of Pelvis.

A curious calculation is made by Dr. Vignard in relation
to the difficulties opposed to childbirth by abnormal narrowness
of the pelvis. The reflection is suggested by a case occurring in
his practice, in which the sacro-pubic diameter of the basin was
eighty-nine millimetres. AH attempts to deliver the child by
forceps proved unavailing, and the accoucheur was obliged to
have recourse to craniotomy.

The woman had already had three children, and according to
the husband's account, the first two, though delivered with
forceps, came into the world alive and well, and were still living.
The third, he admitted to have been born dead, but was still
delivered with forceps. All three were girls. After the patient
had recovered from the effects of the labor (lasting forty-eight
hours), and of the operation, the physician requestioned the
husband, and ascertained that, in truth, craniotomy had been
performed upon this last child. It was not surprising, therefore,
that the fourth, which was a boy, should have required the inter-
vention of the fatal operation.

Hence the obstacle to delivery had continually increased with
each successive birth. There was no reason to attribute this
increase to any greater narrowness of the basis, but rather to what
Dr. Vignard asserts to be a well recognized law, namely : that a
woman's first children are always the smallest, and the size in-
creases with each new birth. Thus, in this case, the first forceps
delivery had been easy, the second difficult, the third accouche-
ment required craniotomy, and finally, in the fourth, the mascu-
line sex of the child introduced another cause of increased size.
As a practical rule, therefore. Dr. Vignard recommends, when-
ever an abnormal retraction of the pelvic cavity has been dis-
covered, sufficient to require the forceps to draw the foetal head
into the superior strait (of course, the application of forceps for
any other reason would not count) , and especially when cranio-
tomy had once been practised — in these cases he recommends
when a new pregnancy occurs, that premature delivery be

no Mary Putnam Jacobi

provoked at the eighth month. For it may be regarded as cer-
tain, that whatever difficulty has already existed, will be pre-
sented again, and in a more formidable degree, and that a woman
who has once lost a child by craniotomy, can never hope for
living offspring, if she waits till term to be delivered.

Cases of Complicated Rheumatism.

M. BoucAND, of Lyons, reports several cases of grave rheiun-
atism, severally complicated with pneumonia, albuminuria haemor-
rhage, or encephalic accidents.

In the first case, the patient was a man about 40 years old, and
when first observed, after an illness of eight days, was in a demi-
typhoid condition, manifested by general prostration, slowness
of speech, dry lips, cracked tongue, great thirst, and slight
epistaxis ; but without any eruption. The pulse was vibrant, and
at 130 — slight cough, mediocre oppression, tubular breathing, and
bronchophony at the summit of both lungs. The patient gave
no sign of sensibility, except when his right thigh was touched
or extended, when he screamed out. A rude bellows sound was
heard at the base of the heart.

The patient was thus affected at once with double pneumonia,
endocarditis, arthritis of the right hip-joint, burning fever, and
stupor. According to M. Boucand, all the other conditions
were under the dependence of the abnormal rheumatism. The
patient succimibed on the second day, but no autopsy could be
obtained.

The second patient was a woman of 34 years, admitted to the
hospital with acute rheiunatism, compHcated by endocarditis.
After admission, she was attacked with pleurisy, accompanied
by very moderate effusion. The urine contained albumen at this
time. The arthritis persisted at the knee and wrist, in spite of
the pleurisy. Suddenly, the patient, who suffered from insomnia,
but whose cerebral functions remained intact complained of
excessive oppression, and sibilant and subcrepitant riles ap-
peared in all parts of the chest. The patient died 36 hours after
this invasion of pulmonary oedema.

The third observation relates to a man 25 years old, attacked
with acute rheumatism for the third time. He labored under
arthritis of several joints, intense fever and sweating, and
repeated and abundant epistaxis. The skin was covered with

Letters to the Medical Record in

sudamina; a soft, blowing sound was heard at the base of the
heart ; bilious vomiting occurred several times.

This patient recovered in 25 days, without preserving any sign
of cardiac disease.

At the same time was received at the hospital a woman four
months advanced in pregnancy, attacked with polyarthritis and
endocarditis. She was affected also with epistaxis and also
spitting of blood. The skin was red, and covered with sudamina.
This patient was seized with eclamptic convulsions several hours
before dying. No autopsy could be made.

In the fifth case, a lymphatic girl, aged twenty-two, was
treated in September for acute rheumatism, and left the hospital,
cured of the acute disease but in cachectic condition, and sub-
ject to diarrhoea. She returned in a month, complaining of
intense cephalalgia. Vomiting, nocturnal delirium, contraction
of the maxillae and the muscles of the neck came on, and the
patient died ten days after admission.

Finally, another woman, 46 years old, was admitted on
account of general feebleness and leucorrhoea, unaccompanied
by organic uterine lesion. She suffered from no heart symptoms ;
but a well characterized organic disease was discovered, and the
patient acknowledged having had several attacks of rheumatism.
The patient was put upon digitalis and a tonic course of treat-
ment ; when, a week after her entrance, new symptoms suddenly
declared themselves, beginning with moderate fever, complete
stupidity, and anaesthesia and hemiplegia of the left arm. The
left side of the face was paralyzed, the tongue deviated; no reply
could be obtained to questions ; complete prostration of strength,
and loss of appetite. The urine contained albiunen. Four
days afterwards arthritis of the right wrist declared itself,
and immediately the intelligence returned, and the left arm
recovered its motor power. A fortnight later, the albumen had
disappeared from the urine, the intelligence remained intact,
there was no more sign of paralysis, and the patient ultimately
left the hospital in a very satisfactory condition.

In connection with these two cases of meningitis (for so M.
Boucand feels entitled to call them), produced under the influence
of rheumatism, the writer reports several cases of adult meningitis
occasioned by othe-^ diseases. In one case it was a pneumonia,
occurring in a person addicted to intemperance. The meningitis

112 Mary Putnam Jacobi

declared itself during convalescence from the original disease,
and at the autopsy the pneumonia was found to be in full course
of resolution; but a soft exudation had developed between the
arachnoid and pia-mater. In another case the cerebral disease
came on during an anomalous variola, where the eruption was late
and scanty, consisting at first of herpetiform vesicles. At the
autopsy a layer of greenish pus, infiltered under the arachnoid, was
discovered on the upper surface of the cerebellum and the inferior
extremity of the spinal cord. In a third case, an erysipelas of
the scalp was the primitive affection, but when delirium declared
itself, the opinion of Trousseau, who declares this symptom to be
insignificant in the course of this disease, invested the prognosis
with an optimism which the autopsy of the patient thoroughly
routed, for the signs of meningitis were evident. Finally, is a
case of meningitis occurring during typhoid fever. The patient
was nineteen years old, and died the 20th day of the disease.
She had coma and stupor, dorsal decubitus, fall of the eyelids,
deafness, cephalalgia, dilatation of the right pupil without
strabismus. The pulse was 100, the skin dry, and the temper-
ature thirty-eight in the armpit. The jaws were so forcibly
contracted as to render examination of the tongue impossible.
Sensibility of the skin remained sufficiently keen; there was iliac
gurgling, and retention of urine with distension of the bladder.
A certain amount of contraction existed in the muscles of the
neck and back ; the thorax was sonorous on percussion, but there
were sibilant and crepitant rales, constipation persistent, and
vomiting of liquid ingesta. Three days before death hallucin-
ations occurred, with contraction of the wrists and carphology,
and the patient ceased to recognize her mother. Several attacks
of epistaxis and tracheal rales preceded the death, which occurred
in the midst of a continually increasing dyspnoea. The urine
evacuated by the sound was red and extremely foetid.

This case is extremely interesting from the curious mixture
of the symptoms severally characteristic of the two diseases
which found themselves in presence, and from the manner in
which the meningitis gradually obtained the ascendency over
the fever, so that at last it seemed to rule alone. But at the
autopsy, the reality of sloth in enteritis was well demonstrated by
two grayish ulcerations in the ileum and at the ileo-coecal valve.
The meningitis was evidenced by a sero-albuminous effusion in

Letters to the Medical Record 113

the anterior subarachnoidal space ; by the thickening and vascu-
larization of the pia-mater, everywhere adherent to the brain;
by adhesion of the two cerebral lobes at the fissure of Sylvius;
by half a glass of thick whitish liquid, like whey, in the third
ventricle. Neither pus nor tubercle nor gray granulation along
the arteries could be found.

M. Boucand remarks, that primitive meningitis is so rare with
adults that, in presence of acute meningical disease, search should
always be made for some other malady which has served as its
cradle.

Nux Vomica in the Dyspepsia of Hypochondriacs.

En Fait de Therapeutique. — There are, as always, one or two
items or suggestions worthy of being placed in the budget. Pro-
fessor Trastour, of Nantes, has occasion to highly praise the
emplojrment of nux vomica in all forms of atonic dyspepsia, and
especially as a relief for the painful digestions so common among
the hypochondriacs. His theory is based upon the two facts,
that nux vomica stimulates and regulates the activity of the
spinal cord, especially in regard to its reflex action, and that the
integrity of the functions of the grand sympathetic is subordin-
ated to the regular accomplishment of the functions of this part
of the nervous system.

The following is a useful formula :

I^. — Pulv-nux vom. i — 4 grammes.
Pulv. cassias ligne£e 2 "
Carb. calc. or carb. mag. 2 grammes.

M. — ft. pulv. 20.

One powder at the beginning of each meal, in unfermented
bread.

M. Trastour, like many of his confreres, prefers nux vomica to
the salts of strychnine, both on account of its innocuousness and
its efficacy in dyspepsias.

Sulphide of Carbon as a local Anaesthetic.

Recent experiments have been made upon the properties of
sulphide of carbon as a local anaesthetic, and have been very satis-
factory. The cold induced is more disagreeable than by the
volatilization of chloroform and ether, but the analgesia is more

114 Mary Putnam Jacobi

profound. A splinter of wood, encysted since two months, was
easily removed under the influence of the sulphide of carbon, after
the operation had been abandoned on account of the pain which
persisted in spite of the local application of ether.

Dextrine in Varicose Eczema.

Finally, a suggestion in reference to the treatment of that
obstinate disease, varicose eczema, cannot be inappropriate.
It is recommended that the limb be swathed in linen bands,
previously dipped in a solution of dextrine, made with 125
grammes of dextrine to a litre of boiling water. Compresses,
dipped in the same liquid, should be laid upon the limb previous
to the application of the bandage. This is then allowed to dry,
and only renewed when it tends of itself to unroll — that is, by
the fourth or fifth day. The eczema should have become toler-
ably dry before this application can be indicated.

M. Devergie, whose name is of such authority in skin diseases,
finds that his patients are infinitely better off with the dextrined
bandage than with the laced stocking. The bandage is useful
even without the dextrine, but the addition of this latter prevents
the linen from becoming soaked with liquids, in which case it can
hardly be removed without tearing a considerable portion of the
epiderm. P- C. M.

The Theories of the Dermatologists of the Hopital St. Louis.

To the Editor of the Medical Record.

Sir — Who, from the commander-in-chief to the smallest cor-
poral in the vast army that wages war on disease, has not heard
of the Hopital St. Louis ? Who, that makes the most flying visit
to Paris, fails to contrive an excursion to its somewhat distant
locality, for at least one walk through its great cool wards,
through the brilliantly clean courts, and spots of refreshing gar-
den? The whole forms a little city in itself, where the most
repulsive forms of disease, assembled in an immense collection
from all corners of Paris, and Europe, and the entire world, are
stripped of a large share of their deformity by the influence of
their surroundings, and a large share of their gravity by the
enlightened skill of the brilliant coterie of physicians who make
St. Louis the arena of their conflicts and triumphs.

Letters to the Medical Record 115

These conflicts, it must be confessed, are not exclusively
carried on between the doctor and the bodies, or skins, of his
patients. It is often a war intra muros, a rivalry of opinion
among the physicians, which is sustained with such vehemence,
that the spectator asks himself nervously, what would be the
consequence if the chiefs of opposing camps should encounter
each other in the morning at the narrow stairway that opens into
the Hospital grounds? The meeting would be more critical
than that of Raphael and Michael Angelo in the Vatican, and,
perhaps to avoid its chances, the different physicians seem to
arrange to arrive at their respective wards at different hours.

The names that are at present associated with the pro-
mulgation of any special doctrine, are those of Cazenave and
Giebert, Devergie, Bazin, and his somewhat wavering satellite,
Hardy. The two first are devoted pupils of Bielt, who himself
was an ardent disciple of Willan and imported the classification of
the English dermatologist at the very moment that in another
ward at St. Louis, Alibert was proclaiming his, — and planting his
arbre des dermatoses in the imaginations of an entranced audience.

Their system, therefore — and I believe it is that best known
in America — considers exclusively the primitive anatomical ele-
ments of cutaneous eruptions, classified as: ist. Exanthemata;
2d, Vesicules; 3rd, Papulse; 4th, Bullae; 5th, Squamse; 6th, Tuber-
cles; 7th, Pustules; 8th, Maculse. Gibert classes lupus elephan-
tiasis, and several other exotic diseases, under the head of
Tubercles ; Cazenave makes of each of them, as well as Purpura
and Pellagra, a class apart; and both recognize the Syphilides as
a separate class.

This system is certainly characterized by an extreme simpli-
city, even an ostentatious absence of all pretension to theory or
doctrine. Distrusting their own ability to discover any connect-
ing links between the multiple phenomena of skin diseases, the
authors confine themselves to making a simple statement of such
phenomena, considered as purely local affections. In a volume
published this year, M. Cazenave reiterates substantially his old
principles, makes light of causes of diseases, which constitute the
basis of Wilson's classification, entirely rejects scrofula even as an
influence in dermatology, and only improves upon his original
programme, by the introduction of certain researches into Patho-
logical Anatomy, which, unfortunately, are more often hypotheses

ii6 Mary Putnam Jacobi

than researches. Thus he declares eczema to be an inflammation
of the sudoriferous glands; impetigo, an inflammation of the
lymphatic vessels; lichen, irritation of the papillae of the derma;
but brings no microscopic proof of his assertions, which are more
or less plausible. Bazin admits the probable lesion of the sudorif-
erous glands in eczema. Devergie acknowledges that impetigo
is generally grafted upon a lymphatic temperament; but Hardy
observes that the papulae of lichen and prurigo do not bear the
slightest resemblance to the normal papillae of the derm, either in
their distribution, which in nowise recalls the regular concentric
lines of the papillary stratum.

In view of the double difficulty in the way of anatomical
researches occasioned by the infrequence of mortality from skin
diseases, and their cessation at the occurrence of any serious
malady, it may be questioned whether, with the assistance of local
anaesthetics, a physician might not extirpate from the skin of a
living patient such a minute segment as would be needed for
microscopical examination. Many obscure points would thus
stand a chance of being elucidated.

Besides this self-restriction to the anatomical characters of
skin diseases, M. Cazenave is further noticeable (and especially
in his recently published work on General Pathology of the Skin)
for an entire rejection of vegetable parasites as intervening even
in favus. Herein he is in complete accordance with the English
dermatologist, Wilson. Now the rival school, composed of M.
Bazin, supported by M. Hardy, and moderately admired by M.
Devergie, is distinguished by its extensive adoption of crypto-
gamic etiologies, by its discontent with "lesions" of the skin, as
the ultimate explanation of its diseases, and by the research after
general constitutional causes for all affections that are not parasi-
tic in their origin. The theories of Bazin have been for some
time on the carpet, but as I believe that they have not widely
circulated on the other side of the water, and as they are ex-
tremely interesting, and, if true, extremely important, I will
expose them in some detail.

The starting-point of the theory is to be found in the generally
acknowledged existence of the great class of Syphilides, affections,
which, though embracing the entire range of primitive anatomical
elements, are all distinguished by characteristic features; copper
color, circular form, white lisere (called Britt's, from the emphasis

Letters to the Medical Record 117

he laid upon this desquamation of the epiderm around a primitive
element); blackish green crusts, grayish ulcerations with sharp
indurated edges; smoothish but indelible cicatrices, etc. In this
case the elementary lesion is common to specific and non-specific
forms of disease; the affection, formed by the grouping of the
elements, as an ecthyma, from pustules, ulcers, and crusts, is
generally common also, although some forms are almost exclu-
sively syphilitic ; but the malady, the general constitutional condi-
tions upon which the affections depend, and which give them their
significance, alone are separate and peculiar, alone assume a
distinct individuality, requiring a distinct therapeutic treatment.
So imposing is this individuality, that it overpowers all other
considerations; should microscopic analysis demonstrate abso-
lute identity between the lesions of specific and non-specific erup-
tions, the prognosis and therapeutics of these latter would remain
none the less dependent upon the diagnosis of the constitutional
disease.

Setting out from this universally acknowledged doctrine, M.
Bazin has inquired if the great class of non-specific eruptions
might not also be brought under the influence of constitutional
diseases. The result of his researches has been the integration of
three great maladies, whose individuality is as distinct, and
relation to cutaneous affections as important, as those of syphilis.
These maladies are. Scrofula, Dartre, and Arthritis, and I
name them in the order in which they have gained public
credence. D^vergie admits scrofula ; Hardy, scrofula and dartre;
Cazenave and Gibert deny even scrofula as regulating skin
diseases; finally, only the pupils of M. Bazin believe in the
existence of arthritis.

M. Bazin gives the following definitions of Maladies, Dia-
theses, and Affections: — "A malady (or disease) is a state of the
body which produces functional disorders, called symptoms, or
material disorders, called lesions. A constitutional disease is a
malady, acute or chronic, pyretic or apyretic, continued or inter-
mittent, contagious or non-contagious, characterised by an
assemblage of morbid products, and of extremely varied affections,
attacking any or all the orgayiic systems.

A diathesis is a malady, etc., characterized by the formation of
a single morbid product that may be deposited in any or all of the
organic systems. Tuberculosis and cancer are examples of dia-

ii8 Mary Putnam Jacobi

theses, and several others are admitted, the haemorrhagic, sac-
charic, fatty, etc.

An affection, is what we commonly call a disease of any partic-
ular apparatus, as the skin, and corresponds to an assemblage
of elementary lesions and symptoms, of which, however, it is not
the cause but the statement. The cause resides in the constitu-
tional disease.

The problem of the diagnosis of any cutaneous disorder is,
therefore, threefold. It is necessary to determine: ist, the
anatomical element, as for instance the vesicle as distinguished
from papulffi, pustules, etc. ; 2d, the affection, as an eczema, dis-
tinguished from herpes, scabies, or other vesicular affections; 3d,
the nature of the disease of which the affection is the expression
for the time being — whether for instance, the eczema be scrof-
ulous, or dartrous, or arthritic. Each case is characterized: ist,
by objective peculiarities proper to the affections of each con-
stitutional disease; 2d, by the coincidence of general symptoms,
equally characteristic of such disease, even in the absence of a
cutaneous affection.

In the diagnostic of constitutional scrofula, M. Bazin does
not greatly differ from the majority of physicians, with whom it is,
of course, the most usual thing in the world to admit a scrof-
ulous constitution, and to consider that it impresses a certain
character upon some eruptions. Only Bazin calls a disease what
others only name a tendency to disease ; the engulphs the lymphatic
temperament (upon which Devergie greatly msists as predispos-
ing to scrofula) with scrofula itself, and he entirely rejects
Cazenave's restriction, for whom chronic inflammation, or
tubercular degeneration of the lymphatic glands, constitutes the
sole expression of scrofulous disease.

Asstuning an exact parallel between the evolution of syphilis
taken as a type, and all other constitutional diseases, M.
Bazin divides scrofula into four periods, each characterized by
peculiar affections, and the two first by special affections of the
skin.

First Period. — Mild cutaneous disorders, including Gourmes
(which Cazenave regards as accidental, and Devergie as depur-
ative), eczema, impetiginous eczema, impetigo; also dry scrof-
ulides, erythema, prurigo, lichen, psoriasis, acne simplex in all
its forms including acn^ sebacea ; scrof ulides_of the mucous mem-

Letters to the Medical Record 119

branes; habitual coryza, seropurulent otorrhoea; glandular
blepharitis; dacriocystitis, with lachrymal tumor and fistula;
scrofulous ophthalmia and keratitis ; reiterated bronchitis ; amyg-
dalitis, stomatitis; certain tenacious diarrhoeas; certain in-
flammations of the vulva and vagina.

For all these affections, as will presently appear, with the
exception of gourmes of the head in young children, M. Bazin
admits the existence of other forms more dependent upon other
diseases than scrofula.

Second Period. — Profound cutaneous affections leaving
cicatrices; lupus, both the erythematous and tuberculous variety;
papulo-pustular scrofulides; impetigo rodens; certain serious
forms of acnd, molluscum; also more obstinate affections of the
mucous membranes, leucorrhoea, with erosions and granulations
of the neck of the uterus ; blennorrhagia with enlarged prostate,
and urethral stricture.

To the Third Period belong affections of the bones and articu-
lations, and to the Fourth visceral and parenchymatous lesions
generally tubercular, with Hectic absent or slightly marked,
although Bazin admits a tubercular diathesis independent of
scrofulous disease. You instantly appreciate the difference
between this view and that which takes into account scrofulous
constitution and scrofulous diseases, but not a scrofulous disease,
with a regular evolution and distinct degrees and stagings. Of
the three (scrofula, dartre, and arthritis), it is scrofula that
approaches most nearly to the standard type, but even here the
critic is forced to object that M. Bazin often strains his analogy
beyond the warrant of facts. Tertiary syphilis never occurs
without having been preceded by primary and secondary symp-
toms; while in scrofula, however frequent may be the instances
of preliminary eczemas, impetigos, etc., M. Bazin himself admits
that a cicatricial scrofulide, a lupus, may declare itself in a subject
who has never suffered from any previous eruption. In this case
he would claim that the links are supplied by some ganglionic
scrofulide — some blepharitis, — and urge the example of syphilitic
patients who suffer from osteocopic pains after the engorgement
of the lymphatic glands has taken place, but without having
exhibited any roseola, papulae, etc.

M. Bazin of course does not pretend to make all the terms of
scrofula correspond to those of syphilis. The initial infection

120 Mary Putnam Jacobi

lacking in the first disease, the affections of its first and second
periods, correspond to those of the second in the syphihtic
malady. The third and fourth periods resemble each other in
the two diseases.

Comparison of the objective characters of scrofulous affec-
tions is best made after the description of the two remaining
constitutional diseases.

Dartre, as you know, is an old French word, formerly em-
ployed to designate all eruptions except those of the head, which
were similarly huddled together under the name of teignes.
Alibert retained the term, though greatly modifying its accept-
ation. Bazin, followed by Hardy, has revived the name, and
applied it, not to a tendency, a habit of body, but to a distinct
constitutional disease, with regular march, evolutions, symp-
toms, etc. He has adopted as a synon3mi, though without
clearly explaining why, the word Herpetic, as the general term
to characterize eruptions dependent upon dartric disease. The
evolution of the dartre is divided into four periods, preceded by
more or less well defined

Prodromata. — These — that would be more justly entitled.
Indications of a predisposition — consist in: scanty transpir-
ation, skin dry, irritable, subject to ephemeral eruptions; thin-
ness; frequent diarrhoea; nervous affections, sick headaches,
gastralgia ; a disposition irascible and melancholy.

The First Period is marked by the appearance of pseudo-
exanthemata, urticaria and zona. Eczema also is of frequent
occurrence at this stage.

Second Period. — Dry herpetides, psoriasis, pityriasis, lichen;
secreting affections, eczema, dartrous impetigo, mentagra, pit-
uite, blennorrhagia, leucorrhoea, rebellious diarrhoeas; often
ascites, and hydropericarditis, increased irascibility, often in-
sanity.

Third Period. — The cutaneous affections tend to generalize
themselves, and visceral disorders occur.

Fourth. — Extreme emaciation; infiltration of cellular tissue;
skin clinging to the bones, covered with scales, crusts, and in-
flammatory exudations; hectic fever, death by syncope.

Of course the only cases where the s^rmptoms of this fourth
period are directly dependent upon cutaneous affections, are
rupia, or pemphigus, and cachectic ecthyma. In all other

Letters to the Medical Record 121

instances a visceral disorder has been induced, under the in-
fluence of the constitutional dartre.

Before commenting on the substantiality of this pathological
entity, I will quote the parallel description of arthritis, the third
darling of M. Bazin's brain, and the most dearly loved of all, for
the very reason that it is entirely ignored by the rest of the
world : —

Prodroma. — Exaggerated transpiration; tendency to obesity
and development of the muscular system; constipation, haemor-
rhoids, sick headaches, congestion of the head, epistaxis, vertigo,
ringing in the ears,

[This description applies evidently to persons with "a full
habit," and subject to the inconveniences and consequences of
constipation.]

First Period. — Articular rheumatism; eczema of the scalp
(before puberty, afterwards it is more disseminated); erythema
of the external organs of generation; oedematous erythema
around the articulations; urticaria, zona, herpes, acute pemphi-
gus, furuncles and anthrax; coryzas, bronchitis and ophthal-
mias; sick headaches and arthritic dyspepsia; vague muscular
pains.

Second Period. — Attacks of gout and of acute articular
rheimiatism; cerebral congestions, anginas, obstinate coryzas;
dyspepsia with burning at the stomach, pyrosis, constriction
of the oesophagus; localized pruritus, especially at the nostrils,
anus, and genital organs ; sometimes anal fissure.

Third Period. — More serious lesions of the articulations,
tophus, destruction of cartilages, caries of bones, ankylosis.

Fourth Period. — Organic affections of the heart; congestions
and apoplexies; catarrhal asthma; various lesions of the liver
and kidneys.

Although M. Bazin, in this extensive generalization, unites
gout and rheumatism like a pair of Siamese twins, he by no means
claims their identity. They both come under the great class
Arthritis, but possess their individual and distinguishing char-
acteristics. In the same way he attaches cardiac affections, not
to rheumatism itself, as generally acknowledged, but to a more
general condition, that embraces the two.

The elaborate specification — which I shall presently expose —
by which affections, similar, but belonging to different con-

122 Mary Putnam Jacobi

stitutional diseases, are distinguished from one another, will bring
out into much stronger relief the peculiarities that are supposed
to characterize these diseases, than this succinct generalization is
able to do. But with that alone before us, we can fairly criticise
its basis, to the extent to which that is independent of the cutane-
ous disorders it professes to explain. Assuming — as I think can
be proved — that cutaneous affections vary in four principal
modes, conveniently designated as syphilitic, scrofulous, herpetic,
or arthritic, and that to each of these modes is attached, more or
less loosely, a liability to certain disorders affecting other parts of
the economy, — we are not therefore obliged to conclude that
each mode constitutes a disease, which constantly holds the
patient in its clutch, menaces him even at moments that the
temporary absence of all affections seems to leave him in perfect
health, and can never be considered cured until it has completed
its entire evolution, and been subdued at the fourth period. The
proof of the existence of such a disease would be found in the
regularity of its evolution, the absence of interversions, the
constant reunion of a sufficient number of characters to establish
its identity. Already scrofula — the nearest approach to the type
exhibited by syphilis — begins to fail in some of these requisi-
tions. (We mean of course scrofula in relation to cutaneous
affections, not the type, glandular scrofula, which often has
nothing to do with them.) Undoubtedly numerous instances
exist, as I have had an opportunity of observing at St. Louis,
where M. Bazin's descriptions are strikingly verified. But
niunerous exceptions exist also. Patients will suffer for years
from rheumatism, even in its gravest forms, and then exhibit
an eruption belonging to the first period of arthritis — a circiun-
stance as embarrassing to the theory as if a gummy tumor should
be followed, instead of preceded, by a chancre ! Others develop
so called constitutional affections, after a lifetime of perfect
health, and I have observed that whenever M. Bazin has to do
with a remarkably robust patient, who seems to have never
exhibited a morbid symptom, he generally ranks him under the
head of arthritis. Again, rheumatism is as frequent among thin,
weakly people, who from their appearance ought to belong ex-
clusively to the domain of Dartre, as to the constipated, obese
individuals whom M. Bazin considers to be alone entitled to its
afflictions. In this particular, the theory seems affected rather

Letters to the Medical Record 123

by old prejudices than by modern ideas. Again, without being
so exigent as to demand that every patient should present the
entire cortege of symptoms proper to his disease, we are at least
entitled to expect the presence of a certain number, upon which
to establish a diagnosis. Yet M. Bazin will sometimes claim an
arthritis from the fact that the patient's father was subject to
sick headaches ; or a dartric because the patient has a bad temper,
and siiffers neither from haemorrhoids nor constipation; or a
scrofula, because the skin is white and the temperament lym-
phatic. In a word, M. Bazin, like all systemizers, being pos-
sessed of a vivid imagination, and a despotic resolve to subdue all
facts to his system, refuses to admit that any diseases, with the
exception of certain exotics, and the parasitic class, can exist
except as dependencies of one of his four great classes, and conse-
quently strains his theory, which, if left in its propqr place, would
be infinitely stronger and more valuable. For, having made all
these deductions, and having changed the too absolute word,
disease, into the more usual and acceptable term, diathesis (to
which M. Bazin gives a forced and arbitrary signification),
there remains an acute and suggestive generalization — wliich, as
we shall presently see, affords much practical assistance in the
comprehension, diagnosis, and treatment of diseases of the skin.
M. Bazin has not condescended to support his views by statistics,
but the suggestion might usefully set other people to work, to
search for confirmation or condemnation of the theory. An
inquirer, who admits that cutaneous affections may be either
accidental or constitutional, will be less embarrassed in the
establishment of constitutional influences, than if obliged mat gre
hon gre, to drag every eruption under such influence; and the
relations between rhetmiatic and cutaneous diseases may be more
clearly discerned, and the dartric diathesis, admitted in France
from time immemorial, more precisely determined, by the obser-
ver who was not self-compelled to prove a regular evolution of a
disease where facts only warranted the irregular connection of
affections — rooted, not in a malady that had possessed the body,
but in the innate tendencies of the body's tissues and component
parts.

In my next letter I will describe the objective diagnosis,
made out in obedience to M. Bazin's theory, but capable of appli-
cation even by those who only admit this theory with modi-

124 Mary Putnam Jacobi

fications, and this will tend naturally to a brief notice of the
therapeutics of St. Louis. P. C. M.

Paris, Aug. 21.

The Pathology, Diagnosis, and Treatment of Skin Diseases.

To the Editor of the Medical Record.

Sir: — The most remarkable instance of the application of
Bazin's theory in the diagnosis of cutaneous affections is afforded
by eczema. According to Hardy, this is always dartrans, and
always — in its chronic forms at least — to be treated by arsenic.
For Devergie it is a constitutional disease, belonging to no partic-
ular diathesis, but expressing a depuratory effort of nature, and
consequently must not be cured, especially in children. Cazen-
ave pooh-poohs this ideal, as in fact do almost all the other
physicians, and declares eczema to be an accidental affection,
whose principal characteristic is expressed in saying that it is a
lesion of the sudoriparous glands. But M. Bazin divides eczema-
tous affections into three great classes, belonging to scrofula,
arthritis, and dartre. Syphilis is represented by vesiculous erup-
tion, or false eczema. Each affection requires a different treat-
ment.

Urticaria, as a manifestation of dartre, is rather pale, and
occurs under the influence of moral emotions. The arthritic
variety is deep red, and occasioned by cold and gastric disturb-
ance. It frequently complicates rheumatism, springing as it does
from the same diathesis. The same distinctions may be made
for acute pityriasis, as when arthritic complicates rheumatism,
when herpetic is accompanied by sick headaches, and determined
by moral emotions.

In arthritic herpes is noticeable the inequality of the vesicles,
already mentioned as a characteristic of eczema. M. Bazin
adds — but very inappropriately — the peculiarity of occupying
uncovered parts of the skin. He thus passes over the well-
known fact that herpes labialis is an extremely frequent compli-
cation of fevers (other than typhoid), and thus may be found
on individuals of all constitutions. The herpes of children is
certainly much more frequently under the influence of dartre
or scrofula than of arthritis, which rarely manifests itself at an
early age.

Letters to the Medical Record 125

Herpes circinatus is regarded by all the St. Louis physicians,
with the exception of Cazenave, as a parasitic disease, originating
in a cryptogam, identical with that producing herpes tonsurans
of the hairy scalp, and sycosis of the beard. The cryptogam is
named tricophyton, and M. Hardy classes these three diseases
together as one, tricophyte.^

In herpes zoster, same distinctions in regard to the vesicles
and antecedents; besides, the pains in arthritic zona are burning,
deep-seated, muscular, and often disappear with the appearance
of the eruption. In herpetic zona (that is, under the influence of
the dartre) , the pain is lancinating, neuralgic, and generally lasts
after the eruption has disappeared.

In herpetic chronic pemphigus, the bullae contain a trans-
parent citrine colored fluid, are isolated, and equal in size. In
the arthritic form, the bullas are sero-purulent, unequal, and
united in large erysipelatous patches. But the cachexia of
pemphigus is the type of what M. Bazin calls the cachexia of
dartre, arrived at its ultimate term, and this is true, however the
debut may be characterized by slight differences. Acute pemph-
igus, according to Hardy, is merely an accidental erythematous
eruption, the bullas being quite secondary to the erythematous
patches upon which they appear, like the phlyctenae in erysipelas.

A curious case of this affection entered M. Hardy's ward the
other day. The patient was a man just recovering from an attack
of lead colic, and had been similarly affected with pemphigus at
the same period of a previous convalescence from the same disease.
On admission, he was as red from head to foot as a boiled lobster.
The fiery patches were not absolutely coalescent, but so nearly so
that the effect was almost as vivid. Upon the greater number the
epiderm was elevated in bullae of different sizes. A slight febrile
movement accompanied the eruption. It was treated like an erup-
tive fever, let alone, and in a week had almost entirely disappeared,
leaving brown stains in the place of the patches, that in their turn
faded rapidly. The affection was therefore essentially distinguished
from real pemphigus, by expending itself in a single eruption,
whereas the more formidable disease is noted for the desperate

' Excuse me if I have mentioned the above idea somewhat dogmatically,
as if on the supposition that it was entirely unknown at home. But Wilson
does not mention this theory, and Cazenave disputes it, and as their works
are the best known in America, I have ventured to be somewhat explicit.

126 Mary Putnam Jacobi

tenacity with which fresh crops of bullae continue to appear. M.
Bazin has a little pet variety of chronic pemphigus — invented by
himself — and entitled, Hydroa with little bullae. This pretty
name is applied to a variety almost as chronic as the ordinary
form, but affording infinitely greater chance for cure. In fact,
whenever a patient affected with pemphigus gets well, M. Bazin
calls his malady Hydroa. But the objective feature is the small
size of the bullae, some of which are not larger than vesicles.
They appear successively, but only one or two at a time, and are
covered by very thin crusts. The general health of the patient
does not suffer the deterioration so remarkable in ordinary chronic
pemphigus.

Bazin professes to distinguish psoriasis, lichen and prurigo
into arthritic and herpetic varieties, but the line is not very well
defined. He observes that the old herpetic affections are always
symmetrical, the arthritic almost always irregular, and not
extending in large confluent patches. Certain horse-shoe and
circular forms of psoriasis, with a shining coppery hue to the
skin, instead of the raw ham look of the non-specific variety —
belong to the cutaneous manifestations of syphilis. The diagno-
sis is evidently of the utmost importance. Besides these
affections, containing varieties that belong either to anthritis or
dartre, are certain others, peculiar to one of these constitutional
diseases. Erythema nodosum, and papular erythema, are both
arthritic, according to M. Bazin. So also, St. Anthony's fire, or
couperose, which he carefully distinguishes from the acne rosacea,
of which it is a frequent complication. But the pustules belong
exclusively to the acne; the couperose is constituted by dila-
tations of the cutaneous capillaries. Acne is always either
arthritic, or scrofulous, or syphilitic, never herpetic. The
scrofulous acne develops on the face; the arthritic affection (ex-
cept the indurated form, which is facial and distinguished from
scrofula, principally by the antecedents, &c.), appears on the
back and shoulders ; syphilitic acne is disseminated all over the
body, and noticeable by the characteristic color of the areola,
and the fine epidermic scales that remain after desiccation of the
pustules. M. Bazin insists upon this latter sign, and in his clinic
mentions cases where its absence has served to correct diagnoses
of syphilis obstinately applied to young persons whose character
was above reproach. Mentagra may be arthritic or scrofulous

Letters to the Medical Record 127

(scrofulous sycosis), but is not herpetic. The arthritic eruption
consists of pustules, seated on indurated tubercles, which occupy
nearly the entire thickness of the derm. The eruption is in cir-
cumscribed patches occupying the beard on the chin, cheeks, or
naso-labial sillon. The crusts are thin, brown, and broken. In
scrofulous sycosis, the crusts are yellow, thick and moist, the lips
are swollen, and the face generally occupied by acne indurata.
The tubercles are more superficial.

Syphilitic acne of the beard, which closely resembles the
mentagra, is still more profound than the arthritic variety; the
sub-cutaneous cellular tissue is inflamed and indurated. Finally,
parasitic sycosis, constituted by the same cryptogamic vege-
tation as produces herpes tonsurans (the tricophj^ton), is notice-
able for the alteration of the hairs, which become gray and lustre-
less in color, broken irregularly, and covered over the roots
with a fine gray powder. On the other hand, nonspecific roseola
is always considered as a manifestation of dartre ; one of its early
symptoms, as papular erythema of arthritis. A certain form
of impetigo, which M. Bazin calls melitagra, is ranked as herpetic,
and distinguished from scrofulous impetigo — which occupies
the head, and appears in large confluent patches — by appearing
symmetrically on the trunk and limbs, in psydracious pustules
more or less isolated.

M. Hardy calls impetigo simply the second stage of eczema,
of which pityriasis is the third, sometimes also the initial period.

Finally (for M. Bazin's dissertations on syphilis do not greatly
differ from those of the rest of the world, and may be left out of
the question), the great class of scrofulides, divided into benign
and malignant, occupy the third place in the category of affec-
tions dependent on constitutional disease — the first, perhaps, in
importance. It is unnecessary to repeat the symptoms of
general scrofula, recognized by everybody. M. Bazin errs,
perhaps, in absorbing into scrofula the lymphatic temperament,
which, though tending towards scrofula, is distinct from it. As
symptoms of the first period of scrofula, he reckons the benign
scrofulous eruptions, classed as exsudative, erythematous, and
papular, and distinguished from the malignant scrofuHdes by
leaving no mark or cicatrice. In the first class (exsudative),
are red gum, eczema, impetigo, and acne sebacea. The char-
acters distinguishing eczema and impetigo have been mentioned

128 Mary Putnam Jacobi

above. All forms of sebaceous acne, whether fluid or concrete,
are recognized as scrofulous. An interesting case of this trouble-
some affection was admitted to M. Bazin's ward a little while
ago. A girl of sixteen, florid and stout, without, however, any
appearance of scrofula elsewhere, or any derangement of health,
had been unsuccessfully treated for a year in the attempt to
remove a patch of concrete sebaceous matter, about three
centimetres long, situated just above the right eyebrow. If this
were scraped away it immediately reproduced itself, and con-
stituted a disagreeable deformity, being a thick, yellow, unctuous
mass, clinging like a plaster to the forehead. Treatment by
cod-liver oil and daily alkaline baths, removed the patch en-
tirely, but the patient declared, from former experience, that it
will return as soon as the treatment was interrupted. She is still
at the hospital.

The papular scrofulides are somewhat discutable. Strophu-
lus is certainly often an accidental affection. Prurigo mitis, with
large papules, and only a supportable degree of itching, is con-
sidered scrofulous, while prurigo ferox always belongs to dartre.
Erythema papulatum can be distinguished by no objective char-
acters from arthritic erythema. I have mentioned above that
facial acne was always scrofulous, that is, the varieties simplex
and punctata, and occurring in young persons.

Among erythematous scrofulides M. Bazin counts chil-
blains; especially those accompanied by deep-seated chronic
inflammation of the subcutaneous tissue, — ^locality affected in
preference by the scrofulides.

The following are the characters common to all the benign
scrofulides: — Tenacity, persistence in the same place (in opposi-
tion to dartre, so noticeable for its mobility) ; debut by the head,
gradual extension to the ears, face, and body; inflammatory proc-
ess secreting, suppurating or hypertrophic : participation of the
lymphatic glands, and subcutaneous cellular tissue; absence of
pain or of intense itching. This latter circumstance is due to the
deep seat of the inflammation. If it chance to be superficial
itching becomes quite intense.

The malignant scrofulides (which, according to Cazenave, are
all manifestations of hereditary syphilis) are remarkable for their
extension to the deep layers of subcutaneous tissue, for their well-
defined limits, and persistence in one place, for the absence of all

Letters to the Medical Record 129

pain or itching, and for a strong tendency to relapse after cure.
These eruptions are divided into three classes : ulcero-crustaceous,
tuberculous, and erythematous. The crustaceous scrofulide
contains two important varieties, inflammatory-ulcerating, and
ulcerating with fibro-plastic formations. The first commences
with tubercles or pustules simply inflammatory, which degener-
ate into ulcers, that destroy surrounding soft parts, but are
arrested by the bones. These ulcers cover themselves with
thick, green crusts, imbedded in the skin, and formed of super-
posed and concentric layers. Impetigo rodens and rupia are
here included. After the crusts have fallen, and the ulcers
healed, there remain white, irregular cicatrices, retracting the
tissues like those of a burn, and adherent to the bones. In the
second variety, the tubercles are fibro-plastic, caused by a prolif-
eration of the cellular tissue, and the ulcers attack the bones
as well as the soft parts. It is to this variety that M. Bazin
especially applies the name of lupus vorax, which is considered an
independent disease by some other dermatologists. He admits
the title also in the second class, or tuberculous scrofulides. The
primitive element is in this case the same as in the other, an
inflammatory or fibro-plastic tubercle, but it remains stationary,
without ulcerating on the surface. Curiously enough, however,
the cicatrices are produced precisely as in the case of open ulcers,
new fibrous tissue being called upon to fill up the place left vacant
by the subcutaneous destruction of cellular tissue. Cure is only
obtained at the expense of such cicatrices.

The same is true of the third class, erythematous scrofulides.
These appear as a circumscribed patch of erythema, at first
seeming to be as innocent as the ordinary ephemeral eruptions.
But it presently reveals its real nature by its long persistence, its
dull, pale red color, the pasty suboedematous feeling on pressure
of the subcutaneous tissue, the absence of all burning, itching,
pain or fever — finally, the appearance of a white irregular cicatrix
in the centre of the patch, which gradually extends to the
circumference.

Among erythematous scrofulides M. Bazin also includes the
singular affection described by Devergie as Herpes cretacea. In
the case quoted by this latter writer, and which was, according
to him, mistaken for an erythematous scrofulide, the disease
began by an intense redness of the end of the nose, which persisted

130 Mary Putnam Jacob!

with great tenacity; then the surface became furrowed, and
from the furrows oozed a yellowish secretion, which hardened
into thick, yellowish, prominent scales. The form of the patch
was round, and it extended by new rings at the circumference.

Malignant scrofulides are distinguished from cancer, by the
edges of the ulcers, which are undermined, instead of prominent,
bosselated and indurated; by the bottom, which does not present
the hard, fleshy granulations of cancer ; by the debut with several
tubercles grouped together, instead of a single one, and by the
complete absence of pain.

The diagnosis with syphilis is often much more difficult, since
the eruptions in both diseases are painless, indolent, chronic, and
composed of similar elements. But the syphilides are less chronic
than the scrofulides ; they date by months, but the latter by years.
This is especially true of the erythematous scrofulide; a case in M.
Hardy's ward now, has lasted ten years. In fact, there seems to
be hardly any tendency to spontaneous cure.

Again : all forms of syphilides, ulcers, tubercles, or crusts, are
surrounded by the characteristic coppery areola, and the tuber-
cles are an obscure livid red. In the scrofulides there is fre-
quently a bluish areola, and the tubercles are semi-transparent.
Syphilitic crusts are blackish-green, and with edges detached from
the skin ; in scrofula, the color is clear green, and the crusts are
firmly imbedded, often like a watch crystal in its case.

Exostosis and necrosis accompany syphilis; caries is pro-
duced by the eating ulcers of scrofula. Syphilitic ulcers are
round, with characteristic edges, and grayish surface. The
regular form is especially noticeable in the ulcers arising from
gummy tumors, and in these the bottom is, in a number of stages,
formed by successive growths of deep-seated gums. The scrofu-
lous ulcers are irregular in form, the edges undermined, the
bottom pale-red. Finally, syphilitic cicatrices are smooth,
shining; scrofulous cicatrices irregular, and formed by the irradi-
ation of innumerable retracting bands.

Scrofulous eruptions are much more frequent on the face;
syphilitic affect the limbs, especially the lower ones; but, as is
well known, often attack the face also, where they possess
favorite localities.

A few words about the therapeutics of St. Louis, M. Bazin's
treatment is in the main ranged under three heads: cod-liver oil,

Letters to the Medical Record 131

iodide of iron, and sulphur baths for scrofulides, malignant or
benign: alkalies, taken internally, and also in baths for the
arthritides; arsenic internally, and saline baths for the herpetides.
He declares sulphur to be positively injurious to the dartre, for
which it has long been the popular remedy, and believes that its
reputation is based on cures of scrofulides mistaken for herpetic
affections. The use of alkalies, especially bi-carbonate of soda, for
arthritis, seems to have been suggested by their employment
in rheumatism, which the theory supposes to be akin to the
eruptions in question. But the effect upon the cutaneous affec-
tions,— especially the influence of Eau de Vichy, — is often very
remarkable. In other words, I have seen skin diseases, present-
ing the characters assigned by Bazin to the arthritides, treated
perseveringly and unsuccessfully by arsenic, while similar cases
in his wards recovered rapidly on the alkaline treatment.

The local treatment is pursued with great care, and comprises
various resources. The actively inflammatory periods of all
eruptions, as eczema, impetigo, pityriasis rubrum, and acute
pemphigus, are treated by emollients, powdered with starch, or
covered with cataplasms. These latter are applied also to indo-
lent pustulous scrofulides, to remove the crusts. Only in zona
and rupia, care is taken to preserve the crusts and vesicles intact,
until the ulcer shall have healed underneath.

M. Hardy obtains extraordinary success by covering the
eruption with vulcanized India-rubber. This retains the in-
sensible perspiration, and keeps the part immersed continually
in a natural vapor bath, which reduces inflammation, allays
burning and itching, and removes incrustations in a very short
time.

An India-rubber cap is often of signal service in eczema capitis
with its tormenting irritation. In one case of severe herpetic
eczema occupying both arms the rubber casing was at first applied
to one only. In a week the scales had fallen, the secretion dried,
the fissures to a great extent healed, and the angry redness was
entirely subdued. The other arm, which only experienced the
effect of the general treatment (tisane of wild violets and senna,
acting as a derivative purgative, a favorite remedy with M.
Hardy in the early treatment of all exsudative eruptions), re-
mained in precisely the same condition as at first.

Vapor, cold and sulphur baths, and douches, are of course

132 Mary Putnam Jacobi

largely included in the local treatment, but with about the same
indications as are observed in other places than St. Louis. But
many forms of disease are treated more boldly on a substitutive
plan, than is generally the case elsewhere. Acne, for instance
(which Hardy pronounces an accidental disease), is attacked by
mercurial ointments and lotions of corrosive sublimate, with or
without general medication.

Malignant scrofulides are painted with tinctures of iodine,
ordinary or caustic, with oil of juniper, or of mahogany nuts.
The two last remedies seem, in M. Bazin's hands, to exercise a
real and marked influence over lupus and other scrofuUdes; and I
have seen the mahogany oil succeed in several extremely severe
and obstinate cases, that have resisted every other application.

M. Bazin advocates also creasote, nitric acid, nitrate of mer-
cury, also perchloride of iron for Lupus vorax. But I have never
seen him apply either. The iodine does not seem to be so gener-
ally successful, though it succeeds in some cases.

The ordinary application for psoriasis is tar ointment. If
that produces too violent irritation, a pomade of oxide of zinc
and camphor, or calomel ointments are substituted. To calm
the torments of lichen and prurigo, ointments of cyanide of
potassium, 5-10 centig. to 30 grms. of lard, are employed. Also
ointments containing i grm. of calomel and 2-3 grms. of tannin
to the 30 grms. Similar applications are made in chronic eczema,
which is also treated by the bichloride of mercury in ointments
and lotions, by M. Hardy.

For pemphigus foliacea, and cachectic or syphilitic ecthyma,
much reliance is placed upon a mixture of quinquina and powder
of worm-eaten wood, as a palliative.

Bazin pronounces decidedly upon the appropriateness of
curing eruptive affections of children. Cazenave admits the
same advisability, though he recommends precautions. Both
observe that the affections left to themselves, frequently tend
to become inveterate, and assume worse forms; infantile eczema
degenerating into chronic lichen, benign scrofulides becoming
malignant, &c. As long as the patient remains under the in-
fluence of the constitutional disease, a relapse of the affection
or of its equivalent, is to be expected as a matter of course, and the
physician must be prepared to combat it afresh, until the dis-
ease be exhausted. But the dangers of repercussion (upon which

Letters to the Medical Record 133

D^vergie still insists), have been greatly exaggerated, and are
chiefly based upon the fact, that the intercurrence of an acute
disease causes the temporary cessation of the cutaneous affection,
even though that be parasitic, as scabies. This (the parasitic
also) returns after convalescence from the intercurrent malady.
The true interpretation of the relation between the internal
and external affections has, therefore, according to the St. Louis
physicians, been precisely inverted. P. C. M.

Paris, Oct., 1868.

Gonorrhoeal Rheumatism.

To the Editor of the Medical Record.

Sir — ^According to Follet, gonorrhoeal rheumatism was
described for the first time by Swediaur in a medical journal
published at London in 178 1, It was subsequently admitted,
though with some indecision, by Hunter. The French physician
above-mentioned, who fully believes in the distinct existence of
this form of arthritic disease, describes it as follows :

It occurs in about i case in 35 of urethral gonorrhoea, upon
which it depends directly, as eSect upon cause, and with patients
who have never before suffered from rheumatism. Relapse of the
urethral affection determines a similar relapse of the articular
with fatal regularity. It is rare among women, probably because
with them the gonorrhoeal flux is more often located in the vagina
than the urethra.

It declares itself at the moment that this flux is most abun-
dant, and the latter generally diminishes with the progress of the
rheumatism, but rarely ceases altogether until that has dis-
appeared. There is, therefore, no appearance of a metastasis,
properly so-called. Debut of the arthritis is sometimes brusque
— by articular pain almost always limited to one joint, especially
the knee, and after that, in point of frequency, the shoulder. At
other times chills, fevers, and gastric disturbance precede the
arthritis, but these general sjntnptoms are always much less
pronounced than in ordinary acute rheumatism. The affection
of the joints may, however, extend from the one first invaded, but
the secondary inflammations are generally less intense, and often
fail altogether.

Follet confirms the interesting observation already made by

134 Mary Putnam JacobI

Hunter, that the blood presents no inflammatory clot, and in that
respect resembles the blood in chronic rheumatism. Cardiac
symptoms are rare, and of little gravity. The articular pains
consist at first of a sensation of stiffness and numbness, but
presently become excessively severe, contusive, boring, lancinat-
ing. Swediaur describes them as frightful. According to Vel-
peau, however, they are sometimes absent altogether. The
swelling of the joint is considerable; the inflammation rarely
mobile, retaining its original place with great tenacity, even when
it has extended its influence to other articulations.

The ordinary duration of this form of rheumatism is 6 to 8
weeks. Follet admits resolution as habitual, and ankylosis as a
rare termination, but other physicians consider the frequency
of ankylosis as among the most characteristic symptoms of
gonorrhoeal rheumatism, and Follet himself notices that the
synovial is more profoundly attacked than in the ordinary dis-
ease. This termination was noticeable in the case of a young girl
recently a patient in M. Gosselin's wards, and that I had an
opportunity of observing. She entered the hospital for a slightly
pyretic rheumatism, apparently generalized, but bearing most
heavily upon the left knee. The case was at first considered an
ordinary one, but in a day or two the general symptoms had
disappeared, and all the articulations were disengaged, except
the knee, where the intensity of the inflammation continued to
increase during three or four weeks. The complete defervescence,
the persistence of great pain and swelling after the redness had
disappeared, caused M. Gosselin to fear the formation of a white
swelling {tumeur blanche), although neither the patient's ap-
pearance nor antecedents indicated scrofula. The limb was
placed in an immobilizing wire gutter, and the inflammation
constantly combated by emollients. The inflammation finally
subsided about three weeks later, but the joint was perfectly
ankylosed in extension. Examination then made for the first
time discovered a purulent oozing from the urethra, and the
patient acknowledged the previous existence of blennorrhagic
accidents.

This case is the more interesting because many persons have
denied the existence of blennorrhagic rheumatism in female
patients. The reason above quoted from Follet, and the greater
difficulty of exploration, and more frequent attempts at conceal-

Letters to the Medical Record 135

ment on the part of the women, may serve to explain this
difference.

M. Foumier observes that he had only been able to find four
observations of such coincidence, related by authors, of which two
were by Cullerier and two by Richet, but he himself has recently
come across four others all at once, and describes two at length.
In the first case the pain commenced at the hip, then successively
invaded the knee and the ring-finger. The wrist was somewhat
swollen, but movements intact. The patient was pregnant, and
examination (notwithstanding denial) discovered greenish pus at
the urinary meatus. The rheumatism gradually invaded the
extensor tendons of the hand, and the pain remained atrocious for
three weeks. As it diminished, the gonorrhoeal flux diminished
also, and changed color, but the metacarpophalangeal articulation
of the ring-finger ankylosed completely.

In the second case the rhetmiatism occupied exclusively the
tendons of the pes anserinus at the right knee, and of the femoral
biceps at the left. The articulations were healthy, but move-
ment extremely painful. Complete absence of general symptoms
and of rheumatismal antecedents. Coincidence of a pregnancy
of several months, and of well-marked urethral gonorrhoea.

I will make a last quotation of an observation related by M.
Peter, and which formed the starting-point for the long discussion
at the Academy. The patient entered the hospital with a bi-
lateral sciatica, and pain upon pressure on the spinal apophyses
of the umbar and cervical vertebras. Cutaneous sensibility was
deadened in the legs, and especially the feet, which were be-
numbed at the soles. The gait was enfeebled and limping. Fin-
ally, the circular pain around the waist helped to decide the
diagnosis of marked disease of the spinal cord.

It was subsequently discovered that the patient was also
suffering from his third attack of gonorrhoea, dating from three
months previous. The sciatica was of ten days' duration, and the
douleur en ceinture three.

Three-inch scarifying cups were applied to the lumbar
region, and copaiba and cubebs administered internally. The
pain was immediately diminished the next morning, but the
feebleness remained the same. Vapor douches were ordered
after the second day. The cupping was repeated three times
in the course of thirteen days, and the pain and gonorrhoea

136 Mary Putnam Jacobi

diminished together, and markedly, on the fourteenth day,
occurred a pain in the temporo-maxillary articulation, speedily
relieved by laudanized cotton wool. On the 23d day, pain in the
right knee, also relieved in the same manner. At this period the
vapor douches were replaced by sulphurous, and these triumphed
over the feebleness and numbness remaining in the limbs. A
month from the date of admission the patient left entirely well,
thus happily exchanging the original diagnosis for that of a gon-
orrhceal rheumatism. Many other similar cases have been placed
on record, of which I will only mention that inserted in the
Archives of Medicine by Fereol. A gonorrhoea of five months'
standing was complicated by a mono-articular arthritis of the left
wrist, and, a month later, by an oedematous phlegmon of the left
submaxillary region, whose point of departure existed in the
inflammation of a lymphatic ganglion at the angle of the jaw. In
three days this phlegmon had extended from the cheek-bone to
the clavicle, but without comprising the parotid. It presented a
lardaceous, almost woody hardness, but was neither vasculated
nor fluctuating. The redness was bright, the pain exquisite.
The phlegmon was punctured with the trocar, giving issue to a
quantity of pale fluid blood, mingled with serosity. and the oper-
ation was followed by complete cure.

The physicians who debate on the question actually diminish
the proportion of coincidences between gonorroeha and rheu-
matism from I in 35 (as stated by Follet), to i in 62.

Upon these coincidences what opinion is to be formed ?

In the first place, the necessity for any peculiar opinion may
be altogether denied, on the ground that the coincidence is merely
casual, a gonorrhoeal patient catching rheumatism like any other
when exposed to accidents of cold, etc. Against this idea are
opposed the arguments: ist, That in patients liable to this
duplicate affection, relapse of either of its branches is almost
invariably attended by the appearance of the other. Its com-
parative rarity therefore, should not count against its reality,
more than in the case of any other disease. 2d, That the rheu-
matism which coincides with gonorrhoea possesses peculiar char-
acteristics, sufficing to distinguish it essentially from ordinary
articular inflammation. The first argument is sufficiently stated;
the second deserves some consideration.

Reference to the description given at the beginning of this

Letters to the Medical Record 137

article will show that the arthritis in question is that long known
as mono-articular rheumatism, and recognized as notably differ-
ent from the generalized disease, either acute or chronic. Its
entire obstinacy to the quinine treatment is not the least interest-
ing distinction that can be made in its character. The less
frequent and intimate connection with cardiac disease is another
important circumstance, though by no means always to be
relied upon. I saw a case last summer at La Charite, of mono-
arthritis of the left tibio-tarsal articulation, accompanied by a
pericarditis that proved fatal. Still, in a general way, these con-
siderations, and those already mentioned, really suffice to estab-
lish a specific separation of this disease from ordinary rheu-
matism. It now remains to be decided, whether this species
should itself be divided into simple mono-articular rheumatism
and that essentially connected, either as cause or effect, with
gonorrhoea.

As I have already reached my limits, I defer this question
to my next letter. P. C. M.

Association of Rheumatism and Chorea.

To the Editor of the Medical Record.

Sir — As I have had occasion already to notice, rheumatism,
in the estimation of European physicians tends continually to
enlarge its sphere of influence, and to take its place as a widely
ramifying constitutional disease by the side of scrofula and
syphilis. Under the name of arthritis, M. Bazin attacks rheu-
matism of the skin as endopericarditis ; M. Bouilland pursues
rheumatism of the heart, and Roger, See, Botrel, Axenfeld,
Trousseau, and others, detect its malignant intervention in the
production of neuroses, and especially the chorea of childhood.
The connection between rheumatism and chorea had already been
signalized by StoU and Sauvages; by Bouteille, who first distin-
guished chorea from the epidemic St. Vitus' dance, with which it
had been confounded by Sydenham; and in England Copland,
Bright, Abercrombie, and Begbie, had insisted with more or less
emphasis on the common parentage of the two diseases. This
view was, however, deliberately defended in extenso for the first
time, in 1850, by Botrel, in an inaugural thesis, and by S^e, in
a memoir subsequently recompensed by the Academy. Trous-

138 Mary Putnam Jacobi

seau, in his Clinique M^dicale, adopts the views of Professor S^e,
whom he accuses, nevertheless, of a certain exaggeration; and
Roger, physician at the children's hospital, in a series of articles
recently published in the Archives of Medicine, furnishes a
number of observations tending to prove that in children rheu-
matism and chorea accompany and alternate with one an-
other, as frequently as rheumatism and endo pericarditis in
adults.

Rheumatism can no longer be defined as a mode of inflam-
mation characterized by its predilection for serous membranes.
No tissue of the economy — fibrous, muscular, mucous, nervous —
is exempt from its ravages. It is pre-eminently a general, con-
stitutional disease, whose affections or manifestations may be
classed in three groups — synovial, visceral, and nervous. Neither
one of these groups is a cause of the others, but all are equally
rooted in the common rheumatic vice. A patient does not have
endocarditis, or rheumatic pleurisy, or meningitis, or chorea, as a
consequence of his articular inflammation, or as a result of its
metastasis, but the internal, as well as the external affection
occurs as another symptom or manifestation of the general rheu-
matism that has possessed itself of his entire organism. The
visceral or nervous affection may precede, or accompany, or
follow the articular, just as the symptoms of pain may precede,
or accompany, or follow the symptom of swelling in rheumatism
of the joints. But in neither case is it relative of cause and effect
that exist between the elements of the double phenomena,
but a common filiation in a general condition that embraces them
both.

M. S6e remarks that there is hardly an affection of the nervous
system that may not declare itself under the influence of rheu-
matism— tetanus, delirium, muscular contractions, apoplexy,
meningitis, and especially chorea, which occupies us for the
moment. The professor ranks in three categories the cases in
which the association of rheumatism and chorea has been
observed.

1st. Categ. chorea, preceded by rheumatism j ^^^-^ pains i\o

2d. Chorea accompanying rheumatism -I ^^^^^ pains. ) 8

3d. Chorea accompanying external or internal i 30, of which J
rheumatism \ 7 were fatal J

Letters to the Medical Record 139

Finally, M. See ranks in a fourth category a certain number
of cases (17), the only ones open to doubt, where the chorea was
accompanied by a visceral rheumatism exclusively. The total
is then 140.

M. Roger, for his part, undertakes to furnish cases: ist.
In which the chorea develops simultaneously with the rheu-
matism, or so soon after the latter affection, that the common
filiation is apparent at once, 2d. Where the rheumatism mani-
festly engenders the chorea, which in its turn occasions an attack
of rheumatism, and where this alternate generation attests the
parentage of the two diseases.

The first class contains three subdivisions. (A.) The chorea
declares itself during the convalescence, or shortly after the
presumed cure of a rheumatism. (B.) The chorea complicates
the rheumatism during its period of greatest intensity. (C.) The
rheumatism and chorea make their first appearance simultaneously.

The first case is the most common, the articular inflammation
seeming to transform itself into chorea with most facility during
its period of decline. It might be said that the general rheu-
matism, having expended its violence in one direction, and
forced by the strength of nature or art to beat a retreat, aimed a
Parthian dart as it took to flight. There is, therefore, or should
be, after the apparent establishment of complete convalescence,
a moment of extreme anxiety for the physician, of which the
patient is happily unconscious. The fever has fallen, or even dis-
appeared; the swelling, pain, and heat have been exorcised at
the articulations; but there remains an indefinable something,
sufficient to indicate that the child is still menaced by his insid-
ious enemy. It is at this moment that the choreic movements
generally make their appearance.

Obs. 1ST. Polyarticular, subacute rheumatism in a child of
II years. 15 days after recovery a severe generalized chorea.
A scarlatina complicated the neurosis, and during the fever the
muscular disorder was aggravated, but diminished rapidly and
pari passu with the exanthem. An arsenical treatment, 2.10,
milligrammes a day, had been instituted for the chorea, but was
interrupted by the scarlatina. The heart remained unaffected.

Obs. 2D. Extremely slight attack of articular rheumatism in
a child of 5 years old; a few days after recovery occurred a severe
generalized chorea. During the interval, the child had been

140 Mary Putnam Jacobi

frightened by witnessing an epileptic convulsion, but the chorea
was not developed until four days later, and could not, therefore,
be referred to the moral emotion, which always produces its effect
immediately, when it exercises any influence at all.

Obs. 3D. The child of rheumatic parents suffers a slight
attack of febrile articular rheumatism of the lower limbs, which
only lasts a week. Eight days after recovery chorea commenced
violently, manifesting itself by grimaces, movements of hands
and feet, agitation in the gait, difficulty of speech, diminution of
sensibility and intelligence. No fever, heart normal. In this
case, as in many others, the intensity of the chorea was in remark-
able contrast with the mildness of the rheumatism.

Obs. 4TH. Acute polyarticular rheumatism, with pleurisy,
in a girl of 14. Menstruation established for eleven months.
Rheumatism severe, followed by a chorea of medium intensity.

Obs. 5TH. Rheumatism with pericarditis in a child of 12.
During the decline of the rheumatic pains, a slight attack of
chorea, which disappeared in three weeks. Palpitations and
rubbing sound at the prascordium persisted.

The chorea, observes M. Roger, was not dependent upon the
pericarditis but upon the rheumatic vice, which, having affected
two different parts of the economy, finally attacked a third.

Obs. 6th. Acute articular rheumatism; during the decline
severe chorea; recovery. A year later chorea and slight endo-
carditis. Cure of both affections.

(b.) This Class Contains Observations of Rheumatism, Accom-
panied by Chorea during its period of intensity.

Obs. 7TH. Endopericarditis, with such abundant effusion
that the life of the patient was seriously compromised. The
following year a long attack of subacute rheumatism, accomp-
anied by a slight chorea, which disappeared gradually at the end
of a month. Neither rheumatism nor chorea returned, and the
heart disease was notably ameliorated.

This case is remarkable, as showing the intimate connection
of the three members of the rheumatic trilogy, even when the
endocarditis, developing itself first and alone, might have been
considered quite independent of rheumatism.

Obs. 8th. Polyarticular rheumatism caused by cold, in a
child of 14. Endocarditis and double pleurisy, nearly simul-

Letters to the Medical Record 141

taneous; slight chorea the 15th day, which increases as the
pleural effusion diminishes. At this moment exacerbation of
rheumatic pains during several days, and as they diminish, the
chorea diminishes and disappears.

In this interesting observation, M. Roger calls attention to
the multiplicity of the rheumatic accidents, their succession,
their so-called metastases. First, rheumatic fever, then in-
flammation of several joints, followed by participation of the
pericardium. The cardiac phlegmasia diminishes, rheumatism
resumes its ascendency, manifesting itself in a double pleurisy.
This in turn yields place to the chorea, which gains ground with
every inch relinquished by articular and pleural rheumatism.
Finally, a month later, when the chorea begins to abate, occurs
a new attack of rheumatism. The most delicate balance seemed
to be maintained between the articular rhemnatic phenomena,
and the muscular disorders of the chorea.

(c.) Observations of Rheumatism Complicated by Chorea from
the Beginning.

Obs. 9th. Several attacks of acute articular rheumatism,
with endocarditis; the last complicated with a slight chorea,
rapidly cured.

Obs. loth. Two attacks of articular rheumatism at a year's
interval, both complicated with chorea and cardiac affection,
occurring simultaneously. Sometimes the chorea predominated,
sometimes the articular rheimiatism, until both affections ceased
altogether, leaving an endopericarditis as a permanent heritage
to the economy.

Obs. nth. Exceedingly slight attack of rheumatism, com-
plicated by severe chorea: pulmonary congestion, followed by
endocarditis. After the amelioration of the latter affection
occurs a relapse of the rheumatism, that continues to be slight.
The chorea persisted in its intensity throughout the whole,
accompanied by a diminution of the intelligence, but was finally
cured, while the heart disease remained permanent.

(d.) Observations of Coincidence and Alternation of Rheumatism
and Chorea.

Obs. 12th. Six attacks of rheumatism and five of chorea,
coinciding or alternating in less than five years. Hemiplegia at

142 Mary Putnam Jacobi

the first relapse of rheumatism, and endocarditis at the
second.

The first attack of rheumatism occurred at seven years
old, and was uncomplicated. Four months later, a second
attack, complicated with hemiplegia and intense generalized
chorea. At nine years, a third — rheumatism, this time with
endocarditis, and a second severe chorea. At ten years, another
combination of rheumatism and chorea. Finally at twelve, a
fifth attack of chorea, this time of slight intensity. After this,
the unhappy patient seemed definitely rid of his rheumatism and
his chorea, but the organic heart disease persisted.

The identity between the three affections is apparent in this
case: the articular inflammation, the chorea, the cardiac phleg-
masia combine, replace each other, confound themselves with
one another, having the same origin and the same termination,
being the triple expression of a unique vice — rheumatism.

The facts proving an intimate connection between rheu-
matism and chorea, may be summed up as follows :

Chorea occurs frequently in children affected with rheu-
matism ; coincidence of the two affections.

Frequently rheumatism is closely followed by chorea; relation
of cause and effect.

Rheumatism may complicate itself with a chorea, which
survives the first attack, but presently is accompanied by a re-
lapse of rheumatism; parentage of the two diseases.

Rheumatism and chorea may arise simultaneously under
the influence of cold, march together, the rheumatism cease,
the muscular ataxy being of more chronic nature, persist, and
finally, as a band of union between the two, may develop an endo-
or peri-carditis ; identity of nature.

Clinical experience proves, not only the frequency of the
relation between chorea and rheumatism, but almost the con-
stancy of this relation; and henceforth the description of the
rheumatism of childhood should include chorea as one of its most
essential elements. These ideas cannot fail to modify the prog-
nosis both of chorea and of infantile rheumatism.

This rheumatic chorea belongs almost exclusively to child-
hood, and is explained by the extreme excitability of the nervous
system in children, easily aroused by the influence of the rheu-
matic vice.

Letters to the Medical Record 143

Chorea is most imminent during the decline of rheumatism,
and as a complication of benign forms of the articular affection,
often limited to vague, ill-defined pains, frequently called
"growing pains." And there is a certain opposition between the
intensity of the two affections, so that severe chorea is more likely
to accompany a slight attack of rheumatism, and inversely, a
severe rheimiatism to be complicated by slight choreic move-
ments. P. C. M.

Paris, May 6th, 1869.
Letters on Albuminuria.

It occasionally happens in the history of scientific research,
that the original discoverers of new truths are able to immedi-
ately divine their consequences, and foresee the problems to
which they will give rise. In this case, the widest subsequent
ramifications of the subject may be traced back to their germ
in the propositions of the original investigator, and the various
doctrines which at different periods have been professed as
exclusive seem all to have been foreboded by him, and to arise
merely from some unduly special emphasis which has been laid
upon one or another of his words.

The comprehensive moderation with which Dr. Bright
announced his discovery of renal lesions as existing in that form
of dropsy which is accompanied by albuminous urine, ^ places him
unequivocally among those farsighted observers who forestall the
disputes of posterity by statements that embrace all sides of the
questions at issue :

"Organic changes occasionally present themselves in the structure of the
kidneys which, whether they are to be considered as the cause of the dropsical
efifusion, or as the consequence of some other disease, cannot be unimportant.
I have often found the dropsy connected with the secretion of albuminous
urine more or less coagulable by heat, and in these cases the liver has presented
no alteration. On the other hand, in the dropsies dependent on liver disease,
the kidneys have been healthy apd the urine non-coagulable. Whether the
morbid structure is to be considered as having, in its incipient state given
rise to an alteration in the secreting power, or whether the organic change
be the consequence of long-continued morbid action, may admit of doubt.

"The more probable solution appears to be that the altered action of the
kidney is the result of various hurtful causes influencing it through the medium
of the stomach and skin, thus deranging the healthy balance of the circula-

' Report of Medical Cases, vol. i, 1827.

144 Mary Putnam Jacobi

tion or producing an inflammatory state of the kidney itself; that when
this continues long, the structure of the kidney becomes permanently changed,
either in accordance with the morbid action, or by a deposit which is its
consequence, but has no share in that arrangement of the vessels upon which
the morbid action depends."

In the first paragraph quoted, Dr. Bright distinctly dis-
engages a triad of phenomena, of which one had been ignored
entirely, another misunderstood, and the third exclusively
associated with a known organic lesion. This triad, renal lesion,
albuminuria, and dropsy, alone deserve the name of Bright's
disease, which cannot be lawfully represented by any one of the
elements taken separately. In the second paragraph he raises
the important debate between the local and general origin of this
disease, and the question of priority of the functional derange-
ment or structural alterations. A collection of twenty-two cases
follows, whose history and anatomical pathology embrace nearly
all the forms that have since been observed. Finally, a classi-
fication of these forms, which are all admitted as equally char-
acteristic of the disease in question, and the suggestion that these
variations may possibly represent the progressive stages of an
affection essentially unique.

It is certain, therefore, that whoever regards Bright's disease
exclusively as a local nephritic disorder, or exclusively connected
with any one renal lesion, or as an incoherent assemblage of
lesions independent of one another, or as a mere functional
phenomenon, not only limits the subject, but limits the intention
of the observer who first introduced the subject to the medical
world.

The history of the doctrines concerning albiuninuria may be
resumed in five periods. The first includes all time previous to
the eighteenth century, during which dropsy was recognized,
studied, treated, and even painted, ^ and attributed to a variety
of causes, especially liver disease, obstruction in the veins, lesion
of the lymphatics. In the middle of the eighteenth century,
Cotugno discovered the second element of Bright's triad, the
albuminuria. The methodical reasoning by which he arrived
at his discovery is worthy of notice. He had observed that the
serous effusions in dropsical patients were coagulable by heat,

' See the horrible picture of Gerard Dow at the Louvre — "La femme hydro-
pique."

Letters to the Medical Record 145

and ascertained that the fluid secreted by the healthy serous
membranes was not coagulable. He concluded therefore that
some new substance had been added to the serous secretion by
the fact of the disease. This was the first step. The second
consisted in an observation entirely independent of the first,
namely, that when the quantity of urine passed by the patients
increased, the dropsical effusion diminished. He inferred that
the kidneys had exerted themselves to carry off the liquid from
the serous cavities. To prove the identity between the surplus
urine and the ascitic fluid, he bethought himself to search in the
former for the coagulable substance which he had previously
discovered in the latter. The same test produced the same
result, the urine coagulated by heat, ergo it had received into its
current the peccant humor of the disease, for which it constituted
a valuable channel of derivation.^

Those who consider renal lesions as the sole and efficient
cause of albuminous urine will hasten to criticize Cotugno's
assumption that the albumen in the urine was derived from that
in the peritoneal serimi. On the other hand we shall find M.
Gubler, in a recent essay, ^ citing the resorption of serous effusions
as a frequent cause of albuminuria. At all events it is certain
that Cotugno's ingenious reasoning led him the first (according
to Rayer) to the discovery of albumen in the urine of dropsical
patients.

Two-thirds of the triad were now constituted; the third link
was added by Bright in his first autopsy at Guy's Hospital. The
patient, John Peacock, had been suddenly attacked with dropsi-
cal swellings of the entire body, accompanied by fever and
constant pain in the small of the back. The urine was sanguino-
lent and albuminous. Death occurred in seven weeks, and at
the autopsy the liver was found to be healthy, but the surface
of the kidneys completely granulated, rough, hard, and uneven.
The cortical substance seemed quite disorganized, but the tubular
portion was healthy.

This coincidence between dropsy, albuminuria, and renal
cortical disease, was confirmed by several subsequent autopsies,
and these three elements henceforth assumed definite and
permanent relations with one another, in a newly organized

' Cotunnius, De ischiade nervosa, pp. 24, 25 (quoted by Rayer).
^ Diet, des Sciences Medicates, 1865. Art. Albuminurie, Gubler.

146 Mary Putnam Jacobi

disease. This is the third period, of which Cotugno's discovery
constitutes the second in the history of anasarca! albuminuria.

The enthusiastic ardor with which anatomical researches
were pursued in the fertile field laid open by Bright — the eclat of
the school of Rayer and of the lessons of Martin Solon —
the application of the microscope by Valentin^ — all tended
to concentrate attention upon the structural alterations of the
kidney, as the sole and essential cause both of albuminuria and
of the anasarca which frequently accompanies it. All the
anatomists confirmed Bright 's original statement — that a
multiplicity of lesions were discoverable coinciding with albumin-
uria. The opinions differed, however, concerning the mutual
relations of these lesions — the German school, after Frerichs, de-
ciding that they represented progressive stages of a unique mor-
bid process; the English, nearly unanimous in maintaining their
independence, or in selecting one or another among the forms as
alone characteristic of Bright's disease. This is the fourth period.

Finally arrives the fifth, which has by no means supplanted
the fourth, but coincides with it, being rather a mode than a
period of thought Here the investigator refuses to arrest his
researches at the kidneys, as the essential and sufficient agent
of albuminuria, but seeks, in the organism at large, the com-
mon cause of their lesion, and of the passage of albumen in the
urine. Valentin himself had suggested this extensive search, in
the very passage in which he describes the first microscopical
examination of a diseased kidney. "The kidneys are only the
receptacle of the abnormal urine," he writes, "and the real dis-
order of secretion must be sought further removed, and in the
blood."

A multitude of questions of the highest interest are resumed
in these two groups of pathogenetic theories. To commence
with the first group, we will first describe in simple succession
the different alterations that have been observed in the structure
of the kidney; afterwards the classifications that have been
framed of these lesions, from the Report of Bright in 1827, to the
recent thesis of Cornil, ^ in 1869 ; finally the inferences that may be
drawn from purely anatomical investigations; clinical histories,

' Reperlorium fur Anatomie et Physiol. 1837.

' Cornil, Nephrites albumineuses — These de concours pour I'agregation,
1869.

Letters to the Medical Record 147

and their combination with the facts of pathological anatomy,
association and causes of symptoms coincident with albuminuria,
prognosis, general pathogeny of this phenomenon, and the diseases
in which it occurs, with their treatment, &c. These topics will
form the subject of other letters.

The cases described by Bright may be resumed, as he in fact
resumes them, into five forms, of which three are principal, and
the other two barely mentioned. In the first case "a state of
degeneracy exists, which seems to mark little more than a
simple debility." It is not very clear what is meant by this
"debility of the kidney," but the description given by Bright
is readily recognizable, and perhaps covers several distinct forms
that later are separated by the microscope. The kidney loses its
firmness, and becomes pale, more or less mottled with yellow,
externally and internally (in the cortical substance). In what
appears to be a more advanced stage of the same lesion, are
found on the surface, white portions, somewhat raised above
the surface, and upon which ramify starlike vessels. Consider-
able spaces (the same?) are quite impermeable to injections.
The tunic adheres closely. The cortex is a uniform yellow color,
sprinkled with small, opaque, and indistinct yeUow spots. The
size of the kidneys is not altered.

This form, says Bright, may be observed in cachexias, even
unaccompanied by dropsy, as in phthisis, diarrhoea, and ovarian
timior; urine only slightly coagulable. This seems to correspond
to the third form described by Rayer.^ The cortical substance
is smooth and pretty equally colored throughout, being pale
yellow, or very slightly rose-hued; sometimes the tint is so re-
markably pale as to resemble an eel's skin. Here and there
appear points of injected vessels, or brown and slate-colored spots
seeming to originate in some former sanguinolent effusion.

At an autopsy performed at La Pitie yesterday, remarkable
on many accounts, occurred a fine example of this anaemic kidney.
The patient had succumbed to repeated attacks of haematemesis,
dependent (as was only clearly proved by the autopsy) upon
simultaneous cirrhosis of the liver and spleen. ^ The kidneys were

' Traite des maladies des reins, 1840.

' The latter organ was 24 centimetres long, and 12 broad, descending
only two finger-breadths below the false ribs, but pushing up the diaphragm
as high as the 5th rib and touching the liver behind the stomach.

148 Mary Putnam Jacobi

normal in size, flattened, and rather less firm than usual. The
capsule was removed with remarkable facility, and the surface
of the organ appeared pale, smooth and polished as marble —
white, slightly tinged with rose lilac. Here and there appeared
little scarlet stellated vessels, isolated, or united in small groups.
On section, the same smoothness and uniformity of color were
observed throughout the two substances. Their relations to
each other seemed normal, unless it were that the cortical sub-
stances were slightly diminished in diameter.

But besides these unequivocally anaemic kidneys, are others
whose pallor is explained by a commencement of fatty degener-
ation. Martin Solon ' describes as the initial stage of the ' ' third
degree," a condition where the kidneys are but slightly hyper-
trophied, with surface smooth and polished, and an extremely
pale yellow hue, like that of the pancreas. Johnson^ repeatedly
describes the "smooth, mottled, — or waxy uniform yellowish
white kidney," as in a state of fatty degeneration. ComiP
observes that in temporary albuminuria, the kidneys, to the
naked eye, only differ from the normal appearance by a grayish''
color, and a certain opacity of their cortical substance; but on
microscopical examination with low magnifying power, 40-50
diameters, the convoluted tubes are found sombre and opaque to
transmitted light, and filled with tumefied epithelial cells. These
are infiltrated with proteic and fatty granulations, and the in-
filtration is the cause of the opacity and whitish appearance of the
cortical tubes.

There is a third morbid process which may be indicated by
these appearances described by Bright and Rayer. In the very
beginning of the amyloid degeneration the kidneys often retain
their normal size, the capsule is easily removed, the surface is
extremely polished, and its coloration, as also that of the interior,
pale, anaemic, slightly yellow in the cortical substance. All parts
of the renal parenchyma affected with amyloid infiltration are
impermeable to injections, which therefore dot the surface of the
kidney with red spots and streaks, contrasting with the pale
ground. Another important character is the occurrence of the

^DeV Album iniirie, 1838. ^ Med. Chir. Transactions, 1846-1859.

3 Loc. cit.

4 "Coloration grise," — almost the same as our pale yellow, or yellowish
white.

Letters to the Medical Record 149

amyloid affection in the course of exhausting cachexias, especially-
dependent upon phthisis and osseous suppuration. Only a small
quantity of albumen ordinarily exists in the urine. ' It is remark-
able that Bright signalizes all three of these circumstances in his
Case III., whose autopsy furnishes him with the type of his
first form of renal lesion.

Although in some cases the amyloid degeneration may be
mistaken for anaemia, or even a healthy condition of the kidneys,
it is generally distinguishable, even in the incipient stages, by the
hardness and leathery consistence of the kidney, and by the hy-
pertrophy of the cortical substance. Microscopical examination,
as we shall presently see, easily completes the diagnosis. En
resume, however, in the slightest (we do not say the initial)
form of change recognizable in the kidney by the naked eye, the
organ is smooth, polished, pale,, uniformly colored in subdued
opaque tints that vary between grayish white and faint yellow,
having lost its natural rosy hue, and something of its natural
consistency, but having retained its volume and the normal
relation of its two substances to one another. Three different
morbid processes may be indicated by these appearances —
anaemia, a commencement of cellular infiltration and fatty degen-
eration, the initial stage of the amyloid affection.

In the second form described by Bright,

"the whole cortical substance of the kidney is converted into a granulated
texture, with copious interstitial deposit of an opaque white substance. As
the disease progresses, this deposit becomes more abundant, and innumerable
specks are strewed through the kidney. Finally, granulations become visible
externally in numerous slight uneven projections on the surface of the kidney,
which is more or less enlarged. The whole cortical structure is often converted
into a yellow substance like fat."

This corresponds to the fourth form of Rayer, who repeats
Bright's description. He observes further, that the granulations
vary in color from flaky white to yellow, are the size of a small
pin's head, or drawn out into lines resembling flakes of curd,
which seem to continue with the streaks in the cones. They are
all veiled by an extremely delicate lamina which covers them like
a varnish. The surface of the kidney over which they are
strewed is perfectly smooth : the cortical substance, in which they
also appear, is hypertrophied and projects between the cones,

' Jaccond, Clinique Medicate, 1867.

150 Mary Putnam Jacobi

whose volume is normal. The hypertrophy of the kidney is
therefore exclusively at the expense of its cortex.

Martin Solon describes these granulations (which he considers
as a comparatively rare form of lesion) as " white, creamy, pultace-
ous, seeming to depend rather upon a sort of interstitial exhal-
ation than a degeneration of tissue." He places them in his
fourth form of albuminuria.

Frerichs' includes the granulations in his second or exudative
stage of Bright's disease. According to him, the surface of the
kidney is still polished between the granulations, and the capsule,
though thickened, is easily removed. But Comil, who seems to
associate a certai-n degree of Bright's third form (hard solutions)
with the granulations, declares that the surface is rough and
unequal, and that in stripping the capsule it is difficult to avoid
removing slices of cortical substance.

Johnson^ establishes the granulations in a third form of lesion,
which itself is only a slight modification of the second — the
large, pale, anaemic, wax-like (or fatty) kidney without granu-
lations. In addition to the granulations, numerous red spots dot
the external and anterior surface.

Christian^ admits the granulations as the second of two princi-
pal forms, inflammation and morbid degeneration. Jaccond
follows Frerichs implicitly.

Andral, in 1823," seems to have anticipated Bright, in a
description of this form of the affection. At the autopsy of a
young girl, who had succumbed to dropsy, the kidneys alone
were found to be morbidly altered. "The cortical substance
and a part of the tubular, were constituted by whitish granular
tissue, divided in little masses which were separated by naturally
colored reddish parenchyma."

We may justly approximate ta the completely granular kid-
neys the second form described by Rayer, in which the kidneys
are enlarged, softened, the cortical substance entirely yellow, and
the surface offering a remarkable mixture of hyperasmia and an-
aemia. The second and the advanced degree of the third form,
established by Martin Solon, exactly correspond to these sub-
divisions signalized by Rayer and Johnson.

' Die Brightische Nierenkrankheiten und deren Behandlung, 1851.

* Loc. cit. Also Med. Times & Gaaette, 1858.

3 Monthly Journal. 1 851. •• Clinique Medicate.

Letters to the Medical Record 151

The close connection that exists between the large, smooth,
yellow non-granular form, and the large yellow granulated variety
of renal alteration, is rendered evident by microscopical
examination.

Valentin,^ in his first investigations, announced that the
granulations were formed by masses of convoluted tubes dis-
tended by yellowish gray material, and hence more distinctly
visible than usual. The straight canals were empty, or contained
a small quantity of fluid. The Malpighian corpuscles were un-
altered. Frerichs, after noticing the mixture of hyperaemia and
anaemia indicated by the alternation of red and yellowish white on
the surface of the kidney, also describes the convoluted tubes as
distended by an exudated material, chiefly contained in the
epithelial cells, and composed of fatty and proteic granulations.
The cells lose their polyhedric form, become round, then irregular,
and finally crumble away into a confused detritus, which blocks
up the tubes and renders them opaque,

A finer exudation is formed in the Malpighian capsule, around
the vascular tuft, as soon as the obstruction of the convoluted
tubes begins to seriously interfere with the current of urine. This
material, consisting of fibrine mixed with fat globules, covers the
capillary glomerulus with thick layers, interposed between it and
the capsule, and their pressure, counterbalancing that of the blood
in the interior of the vessels, gradually arrests the transudation of
water. The blood often flows back, therefore, from the corpuscle
where its presence has become useless, and the capillaries are left
empty.

Associated with the granular and fatty exudation is another
of pure fibrine, which forms hyaline cylinders,^ that assume the
form, shape, and size of the convoluted tubes. When formed in
tubes whose epithelial cells are falling from their walls, they are
"granulated," because the desquamated epithelium becomes
embedded in their substance. But the cylinders, exuded into

' Loc. cit.

* According to Frerichs, these hyaline cylinders are formed by a simple
process of inflammatory exudation, and identical with that which determines
the passage of albumen in the urine. But Cornil considers them due to a
colloid secretion from the cells, or a colloid transformation of the cells, com-
parable to that which takes place in the colloid degeneration of the cells of the
thyroid body.

152 Mary Putnam Jacobi

tubes entirely stripped of epithelium, are large, pale, and waxy,
and perfectly smooth.

Transverse section of the distended tubes often offers the
appearance of little cysts, disseminated over the kidney. These
cysts had been noticed by other observers, ^ but their nature had
generally been misunderstood. Cornil affirms with Valentin
that the granulations of Bright are formed by distended con-
voluted tubes. ^ When the exudation consists of epithelial cells,
simply desquamated, or filled with proteic (fibrinous) granu-
lations, the granulations of Bright are grayish, opaque, or even
demi-transparent. When the granulations of Bright contain fat,
they become decidedly yellow in color. The uriniferous tubes
and glomeruli in the neighborhood are normal or atrophied, and
their collapse contributes to render the distended convolutions
more prominent. Ecchymoses may occur near the circumference
and they result from rupture of the capillary vessels submitted
to excessive pressure by the obstruction to the circulation caused
by the exuded deposit. The red points, once supposed to be dis-
tended malpighian corpuscles, result from such a rupture into
the extremity of a uriniferous tube. The glomeruli, as we have
seen, are empty, or distended by fibrinous exudation — not blood.

The pressure of the granulations known as "Granulations of
Bright" (and which must be carefully distinguished from others,
more commonly met with, and which will be described further on)
constitute, therefore, but a minor detail in the morbid alteration
in question. The essential circumstance is the degeneration of
the epithelium in the convoluted tubes. If this degeneration is
generally diffused, so that the cortex is uniformly distended,
the surface of the kidney, both external and on section, remains
smooth and uniform. If the alteration is unequally distributed,
certain bundles of tubes will be distended, at the same time that
others are normal or collapsed, and will consequently become
prominent above the level of their neighbors.

The hypertrophy of the kidney, exclusively at the expense of
its cortical substance, its coloration, anaemia and hyperaemia, and
its diminution of density, are all explained by this engorgement of

» Wilkes, Guy's Hospital Reports, 1852.

'Wilkes (loc. cit.) considers the granulations to be sometimes formed
by the flaky deposit, scattered over the surface — the yellowish specks described
by Bright and Martin Solon.

Letters to the Medical Record 153

the cortical tubes with epithelial cells, whose abnormal prolifer-
ation has been followed by troubled tumefaction, and finally by
desquamation. But it will be noticed that under the general
description of the minute anatomy of the "large, white kidney"
have been united three very different conditions. In the first,
epithelial cells are filled by proteic granulations. Second, the
same are distended with fat globules. Third, the uriniferous
tubes are stripped bare, and collapse when their contents have
been swept away by the stream of urine which continues to pass
through them more or less freely.

The relations of these different conditions to one another will
be examined later. At present it is only necessary to signalize
their existence, and to decompose the second as we have prev-
iously decomposed the first form of alteration described by
Bright, into three distinct lesions.

Besides the fatty degeneration that accompanies and partially
determines the "granulations of Bright," Cornil admits into the
group of ''nephrites albumineuses," the stearosis occasioned
by poisoning with phosphorus. Lebert^ and Rannier^ relate
several cases of this lesion, whose dependence upon phosphorus
was first insisted upon by Von Hauff in 1860,^ though in 1859
Rokitansky had already related three cases of stearosis of the liver
and kidneys, that he attributed to phosphoric poisoning.

In the cellular tissue which surrounds the kidneys (remarks
Lebert) often exist little ecchymoses, also noticeable on the
mucous membrane of the basin and calices. Capsule is smooth,
easy to separate. On the surface of the kidney appears the mix-
ture of hypersemia and anaemia, already described by Rayer in
the "large yellow kidneys," and dependent upon the obliteration
of a part of the blood-vessels by the exudation, and the engorge-
ment of another part in consequence of this obstruction. Volume
of the kidney normal or increased. Fatty decoloration unequally
distributed. Cortical substance yellow, and often notably
atrophied. Surface smooth and shining, and of pasty consistency.

On microscopical examination the convoluted tubes are found
to be engorged with fat granulations, which cease suddenly on
the threshold of the glomeruli. These latter are congested, but
otherwise perfectly healthy. According to Cornil, the fatty

* Archives de Medicine, Sept. 1868. » Archives de Medicine, 1863.

J Wiirtemberger Correspondenzblatt.

154 Mary Putnam Jacobi

infiltration extends into the straight tubes, affecting especially the
loop tubes of Henle, which become entirely black.

The fibrinous cylinders appear in the urine like a black, finely
granulated, cylindric mass, filled solid, and thickly studded
with fat granulations. This fatty degeneration is only observed
if death be postponed beyond the third or fourth day. It is
accompanied by similar lesions in the liver and heart, a circum-
stance unfavorable to the supposition that the renal stearosis is
an essential affection of the secreting organ of the kidney. The
rapid participation of the straight tubes, long intact in Bright's
disease, and the scanty or doubtful amount of albumen that
generally exists in the urine, also militate against the justness
of Cornil's classification. But the question deserves more elabo-
rate consideration.

We arrive at the third and last form described by Bright.
"The kidney is rough and scabrous, lobulated, and rising in
numerous small eminences. The feel is hard, like that of carti-
lage. The tubular portions are drawn near the surface: there
seems to be contraction of every part of the organ, with less
interstitial deposit than in the preceding variety."

It is this form which is often erroneously called "the granu-
lated kidney." The true granulations of Bright are, as we have
seen, extremely small, mere specks — soft, yellow, and seeming to
be exterior to the parenchyma. The false granulations (which
in reality better deserve the name) are larger, the size of a hemp
seed, hard, evidently formed by the inequalities of the paren-
chyma itself, closely adherent to the capsule. The kidney is
small, "contracted in every part," and has become famous as
"the small, hard, contracted kidney," recognized and described
by all authors. By the picturesque expression that "the tubular
portions seem drawn near the surface" (appearance admirably
represented in his plates) Bright indicates the extreme atrophy of
the cortical substance, which he does not appear to recognize as
the most special feature of the lesion.

Rayer repeats Bright's description in his sixth form. Martin
Solon mentions it as "induration with atrophy," in a class conse-
crated to "accidental degenerations." Wilkes describes the
"puckered uneven" surface of the kidney in this form, and the
complete wasting of the cortical substance, by which the kidney
shrinks to 3^ or ^ its normal size. As a rule, there is no pul-

Letters to the Medical Record 155

taceous deposit, but a large addition of fibrous tissue. Cornil
remarks the multiplicity of lesions which may be found in this
atrophic form — transparent granulations, calcareous incrust-
ations of the glomeruli, atheromatous alterations of the vessels,
cysts formed by distension of the tubes, and great abundance of
fibrous tissue, as in the interstitial nephritis that occurs independ-
ent of Bright's disease. P. C. M.

Paris, July 1869.

To the Editor of the Medical Record.

Sir — The microscopic descriptions given by Frerichs and
Wilkes explain the appearances in the atrophic form. The urini-
ferous tubes, stripped of their epithelium, universally collapse,
as they had already begun to do in the granulations. (See last
letter.) The straight tubes also become indistinct, and at last
almost undistingiiishable, until separated by fine needles.
They are stifled in connective tissue, which originates both in
the proliferation of that normally existing between the tubes,
and the organization of the fibrinous material exuded from the
vascular plexus which surrounds them. The malpighian cor-
puscles in many places are wasted to half their usual size, having
been destroyed in the crumbling away of the proteic and fatty
granulations in the interior of their capsule. Others distend
into little cysts, by the accumulation of urine, when the convol-
uted tube is so blocked up as to oppose its passage, at a moment
wlien the malpighian tuft, still unaltered, continues its watery
secretion. Others, again, remain distended by solid exudation,
and rise in eminences above t9ie uriniferous tubes strangled in con-
nective tissue, thus forming the hard granulations charactertistic
of the atrophic form. They differ from the granulations of
Bright simply in the greater condensation of their contents.
This is the stage of atrophy described by Frerichs as the culmin-
ation of the disease.

Under the first anatomical form described by Bright, we have
considered ourselves justified in recognizing, among other lesions,
an incipient degree of an alteration that has been described as the
"Amyloid Degeneration." In the complete development of this
form of renal affection the kidney is voluminous, heavy, and pale,
and at first sight might be mistaken for the ordinary "large white

156 Mary Putnam Jacobi

kidney," with which, no doubt, it has often- been confounded.'
Closer inspection, however, shows that its consistency is remark-
ably firm, hard, and tough, even leathery. The surface is uni-
form and smooth, without any mottling or deposit, except in the
case of concomitant fatty degeneration of some tubuli; the
cortical substance is hypertrophied, and the whole mass of the
kidney appears composed of one uniform albuminous semi-
translucent substance, except at the apices of the cones. This
appearance is, however, only characteristic of extreme cases. In
others,^ the cortical substance is pale yellowish white, the con-
voluted tubes opaque, with little dots and streaks, and the straight
tubes alone semi-translucent. In some cases (Harris) the mal-
pighian corpuscles are scarcely apparent. In others (Jaccoud^)
they appear upon the surface of section, white and transparent,
like brilliant drops of dew (Meckel).

In the autopsy performed by Harris, microscopical examin-
ation of the fluid expressed from the kidneys, discovered blood
cells, epithelium from straight tubes, cells filled with minute
oil globules, and granular and fatty detritus of cells and nuclei.
Those portions of the cortex which had appeared opaque to the
naked eye, now showed as a black deposit contained within
the tubes, and were seen to consist of granular matter studded
with oil globules. The malpighian corpuscles were remarkably
distinct and semi-transparent.

The pathognomonic appearance of the amyloid kidney is only
observed after the addition of iodine and sulphuric acid. A drop
of a solution of iodated iodide of potassiimi, added carefully
to the slice under the microscope, colors the malpighian corpus-
cles a transparent carmine by transmitted light, orange by re-
flected; streaks of the same color diverge from the corpuscle,
following the direction of the afferent arteries of the tuft. The
same reagent colors orange red the black opaque deposit that
surrounds and invades the convoluted and straight tubes. On
the addition of a drop of sulphuric acid, the color changes to dark
purple, blue, and finally, after a quarter of an hour, deep red,
brown and black.

The seat of this deposit is principally in the coats of the

' Wilkes' Lardaceous Diseases, Guy's Hospital Reports, 1856.
' Harris, Lancet, 1859.
3 Clinique Medicale.

Letters to the Medical Record 157

arterioles and arteries, beginning with the former.' According
to Virchow the muscular coat is attacked Ifirst. Each cell fibre
is replaced by a compact homogeneous substance, in the middle
of which may be at first observed a central space corresponding
to the nucleus which has disappeared. Gradually, however, all
cell structure is lost, and there remains only a fusiform mass,
in the midst of which it is impossible to recognize either mem-
brane, or nucleus, or contents. When the muscular coat is com-
pletely invaded, the inner and outer tunics became involved, and
ultimately the deposit extends to the entire parenchyma nour-
ished by the arteries. This parenchyma becomes ischaemic from
a double cause. The small arterioles lose their propulsive con-
tracting power by the destruction, the sort of petrifaction of their
muscular coat ; and afterwards the thickening of the three tunics
diminishes, and even effaces the cavity of their canal.

According to Grainger Stewart the hyaline cylinders assume
the characteristic coloration with iodine. But Cornil observes
that they undergo no further change upon the addition of sul-
phuric acid, and considers their coloration to result from simple
imbibition of the iodine. This latter author has always found
the deposit extended to the epithelial cells, in cases where albumi-
nuria existed.

There is still another and highly important form of renal
lesion, which Bright describes, but without assigning it a place
in his classification. In his case 14, where the anasarca was acute
and the urine smoky and sanguinolent as well as albuminous, the
autopsy discovered the kidneys in a different condition from
any of the others previously examined. They were large, less
firm, without adherence to the capsule, and of the darkest choco-
late color, tinged with a few white points and a great number of
black, so as to look like fine-grained porphyry. This color per-
vaded the entire organ, but the striations of cortical and medul-
lary substance were preserved. A considerable quantity of
blood oozed from the kidneys upon pressure.

This description applies to an intense hypersemia of the kid-
ney, and is repeated by Rayer, Martin Solon, and Frerichs, in
their first form or degree of Bright's disease. According to the
latter, the volume of the kidney may be nearly doubled, and that
principally at the expense of the cortical substance, which is dark

' Virchow, Pathologic Cellulaire. Trad, frangaise.

158 Mary Putnam Jacobi

red and friable. The renous plexuses on the surface of the cortex,
and surrounding the vessels of the pyramids, are distended with
blood, and the mucous membrane of the basin covered with
vascular ramifications. The malpighian corpuscles are red,
distended, and more distinct than usual, and capillary apoplexies
are frequent, either in their interior or in their neighborhood.

The epithelium is not much altered in this form, but the canals
are filled with coagulated fibrine, in the form of white, transparent
cylinders. These sometimes are observed projecting from the
uriniferous tubes, sure proof that they are formed in their
interior.

In the midst of this general congestion, appear grayish bands
in the cortical substance, formed by the pyramids of Ferrein, and
opaque white lines in the pyramids of Malpighi, consisting of the
tubes of Henle.

The foregoing descriptions embrace all the alterations of the
kidney which have been observed in connection with dropsy or
albuminous urine, in the triad constituting Bright's disease. It
will be seen that they all involve some alteration of the malpigh-
ian corpuscles, or the interior of the uriniferous tubes, and justify
therefore the general name of "parenchymatous lesions," which
has been applied to them. The "interstitial nephritis," which
affects the connective tissue between the tubes, with its various
forms, simple nephritis, metastatic nephritis, and chronic nephri-
tis or cirrhosis, and the special varieties signalized by Rayer,
toxicologic and arthritic^ nephritis, these should be most appro-
priately noticed during the discussion of the causal relations that
unite albuminuria to the parenchymatous affection. For, by
the absence of this phenomenon in the case of purely interstitial
affections, we are at once provided with a logical dilemma that
clears half the field open to hypothesis, and forcibly limits
investigation to the other half.

I have enumerated the lesions of Bright's disease in simple
succession, precisely as they might present themselves to any one
in a series of autopsies. The relations between these lesions,
their arrangement in separate forms or progressive stages, the
efficient and remote causes of hyperaemia, granulations, fatty
degeneration, atrophy, amyloid infiltration; the nature of these

'See also Todd, Clinical Diseases of the Urinary Organs, 1757 and Ball,
Visceral Rheumatism, Th^se de Concours, 1865.

Letters to the Medical Record 159

various morbid processes, their possible influence upon the char-
acter of the urine and on the production of anasarca — all these
questions, discussed at first, exclusively with the anatomical
elements collected in the present letter, will form the subject of
the next. P. C. M.

To the Editor of the Medical Record.

Sir — In a preceding letter we have described the renal lesions
of Bright's disease, per enumerationem simplicem. It is now
necessary to inquire into their logical relations to one another.
The various conditions known as congestion — exudative nephri-
tis, acute inflammatory nephritis, catarrhal nephritis, tubular ne-
phritis, desquamative nephritis — fatty degeneration, smooth large
mottled kidney, fatty stage of inflammation, interstitial nephritis,
gouty kidney, atrophy, small contracted kidney, granular kidney,
cirrhosis — finally, amyloid degeneration, may be regarded in the
light of one of two hypotheses, each equally famous. They may
be supposed to belong to diseases, as distinct and independent as
pneumonia and phthisis, linked together by the common
symptom of albuminuria, as these by the common symptom of
cough. Or, on the contrary, they may be regarded as successive
steps in the evolution of an identical process, as are the gray
miliary granulation, the cheesy pneumonia — the softening and
excavations in the evolution of pulmonary tuberculosis. The
practical importance of decision between these hypotheses is no
less evident than the speculative interest. The boundaries
between the two great divisions into acute and chronic disease
most urgently require settlement. If the renal lesions character-
istic of long standing albuminuria invariably commence in
organic degeneration, the disease is at once chronic and incurable
from the outset. On the other hand, the acute dropsy after
scarlatina and exposure to cold, is radically different from
Bright's disease, and can have no more tendency to pass into it
than endocarditis into fatty degeneration of the heart. But if
the initial stage of certain chronic affections be identical with that
of acute affections tending spontaneously to recovery, the hope
may be entertained of arresting them also in their march, if
taken in time. Finally, the obstinacy of certain other forms of
disease may be explained and predicted by considerations drawn

i6o Mary Putnam Jacob!

from the differences they present in the initial lesion, differences
which indicate their radical independence.

Again, the value of any one symptom among the vast array
coincident with albuminuria cannot be determined until we know
whether it is necessarily connected with the whole range of
Bright's disease, or belongs to a group standing apart by itself.
Does abundance of albumen in the urine threaten uraemia as well
as dropsy? Is diarrhoea likely to supervene when the heart is
affected? Does haematuria indicate an exacerbation of the dis-
ease, and the disappearance of albuminuria its cure? Will a
patient live longer whose complexion is white or sallow? Does
lead or alcohol tend more fatally to the production of Bright's
disease ? If dropsy and albuminuria be the pathological signs of
renal disease, how explain their absence notwithstanding the
existence of extensive structural alterations of the kidney ?

These questions, suggested at random, indicate the infinite
confusion that results, in the absence of the elementary analysis
that shall rigorously attach each physical sign to a definite lesion
of the kidney, and, grouping symptoms rationally or empirically
around such elementary lesions, anticipate their association in the
same manner as these are known to be associated.

We have shown that all alterations of structure in the kidney
may be referred to one of three heads, according as they affect the
blood-vessels, the uriniferous glands and tubes, or the inter-
tubular connective tissue. In the list mentioned at the beginning
of this letter, the first and last class of alterations (congestion and
amyloid degeneration) affect the vascular structure; the second
and third class (exudative nephritis, &c., fatty degeneration, &c.)
involve the glandular elements; finally, the fourth class (inter-
stitial nephritis, &c.) attack the connective tissue. Two ques-
tions are, therefore, involved in the decision of the theory of
successive stages. First, Can an alteration affecting one element
of the kidney pass into another confined to the same element?
Second, Can such an alteration pass to another element, or to
another alteration affecting another element? and having ascer-
tained the possibility of such progression, we must further inquire
into its necessity or invariability. Reply to these inquiries
demands, first, study of the combinations that may be observed
after death, in the same kidney, of the lesions characteristic of
each form of Bright's disease. Second, study of the combination

Letters to the Medical Record i6i

and order of succession that may be presented during life by the
groups of symptoms characteristic of the same forms.

We have already described at length the anatomical lesions.
Before studying the combination of signs and symptoms, it is
necessary to define the groups, and ascertain if they can be
rationally or empirically attached to special lesions.

And here it is necessary to distinguish. Zimmerman,' in
despair at the variety of symptoms that may coincide with the
same anatomical alterations, seeks in the blood and general
state of the system an explanation that pathological anatomy
alone is unable to give. This confusion mainly arises from the
qualitative differences that may be introduced by qualitative
variations. Thus, to anticipate in our description, with equal
degrees of alteration of the glandular and interstitial elements of
the kidney, urasmia would be imminent in the first case, and
scarcely possible in the second. But should the interstitial tissue
become still more compromised, ursemia might supervene with
the same facility as in the course of tubular disease, and the
same result be reached later and by a somewhat different
mechanism. Time must, therefore, always be taken into account,
in determining the relation between a symptom and any given
lesion.

The composition of the urine affords the best point of depart-
ure, especially in regard to its water, urea, and the morphological
elements that may be abnormally present. The conditions which
determine the transudation of albumen, being themselves open to
much discussion, the variations of this constituent are of less
value in the elementary diagnosis of renal lesion, and will be con-
sidered later. But in the absence of general causes, such as exist
in cholera or fevers, the diminution of the quantity of water
excreted by the kidney necessarily implies either alteration of the
capillaries through which it should have been transuded, or
obstruction of the tube through which it should have been
excreted. Again, the presence of blood in the urine is positive
proof that the capillaries have been ruptured by over-distension;
of epithelium, that the urinary tubes are losing their lining ; of oil
globules, that fat exists in abnormal quantity in the gland cells;
of casts, that some foreign substance has exuded into the tubes
and moulded itself upon them. If the diameter of these casts be

^ Deutsche Klinik, 1855.

1 62 Mary Putnam Jacobi

less than that of the tubes lined with epithelium (rcW) it is cer-
tain that the epithelium is still in place; if large (-p-J-Tr) that the
tube is denuded. Casts covered with epithelium indicate des-
quamation of the urinary tubes; granular casts, the crumbling
away of their epithelium, after a longer duration of disease; casts
black and shining with oil globules, extensive fatty infiltration
and degeneration, with complete destruction of epitheliimi.
The qualitative analysis of these elements must be controlled
by estimate of their relative abundance. In small quantity
they have little significance, since the fall and renewal of epithe-
lium cells, the deposit of fat between their wall and nucleus, the
exudation of pale, transparent, finely granular cylinders formed
of mucine (Cornil) are ordinary phenomena of health. More-
over, Johnson and Dickinson^ have noticed an abundant deposit
of oil in the renal epithelium, in cases of chronic extra-renal dis-
ease,— deposit formed here, as in the epithelium all over the
body, to remain temporarily and then be absorbed. On the
other hand, an immense amount of oil, associated with com-
plete destruction of the epithelium, is as unsafe an indication of
Bright's disease as a small quantity contained in normal cells, for
it is characteristic of the acute, fatty degeneration caused by
poisoning with phosphorus, ^ and is entirely independent of idio-
pathic nephritis. Finally, a considerable amount of urinary
deposit may be formed in consequence of lesions occupying a
comparatively insignificant extent of the renal structure. The
inferences drawn from it, therefore, should always be controlled
by considerations of the quantity of urine and of urea, state of the
blood, general symptoms, &c.

Congestion. — The characteristic sign of congestion is the
presence of blood in the urine, — and reciprocally, we have seen
that the presence of blood always indicates some degree of con-
gestion. It may exist in microscopic quantity, only recognizable
by the form of the blood-corpuscles or be sufficient to render the
urine smoky or black. Sanguinolent urine is necessarily albumin-
ous, even in the absence of conditions that might determine the
transudation of albumen through unruptured capillaries. In this
case the albumen is derived from the effused blood, and varies in

' Pathology of Albuminuria.

' Cornil, These de Concours, 1868. Ranvier, Archives gen., 1863. Leh-
bert, Archives gen., 1865.

Letters to the Medical Record 163

the same proportion, which is not the case when congestion
complicates pre-established albuminuria. There are two condi-
tions in which the kidney becomes entirely congested, ist, during
the convalescence from certain acute diseases, — principally
scarlatina; 2d, idiopathically, after exposure to cold.

In the first case, the urine becomes suddenly albuminous and
smoky, and the cellular tissue throughout the body invaded by
cedema, but there is no pain in the loins, fever, or any exacer-
bation of the original disease. In the second case, when the
affection occurs in the midst of health, the general symptoms are
more distinctly marked; there is general malaise, lassitude, per-
haps slight fever, loss of appetite, nausea. An attack of acute
congestion, however, remains scarcely ever limited to the re-
pletion of the blood-vessels. The lining of the uriniferous tubes
is irritated, and the congestion passes insensibly into the second
form — catarrhal nephritis.

Its characteristic sign is the presence of epithelial cells in the
albuminous urine, mingled with the blood-corpuscles. These are
remarkably abundant in scarlatinous albuminuria, and when
death occurs in the course of this affection, the cortical substance
is found nearly white, all the convoluted tubes being stuffed with
young epithelium. According to Rindsfleisch, these young cells
come from cells formed in the conjunctive tissue of the peripheric
stroma, passing into the uriniferous tubes across pores pierced
in their basement membrane. In the urine, as in the tubes, they
are found voluminous, and in a state of troubled tumefac-
tion distended with albuminous granulations that partially
mask the nucleus. These disappear on the addition of acetic
acid. Many of the cells are found in various degrees of dis-
integration, or even filled with fat globules, which appear as soon
as the desquamation has lasted for a few days.

This simple catarrh, the almost immediate consequence of
congestion (which itself may be insufficient to render the urine
smoky, and only be manifested by the presence of blood-cor-
puscles in the urine), is not attended with symptoms of greater
severity than the congestion alone. In scarlatinous albumin-
uria the renal lesion often arrests itself at this point. In the
albuminuria supervening after exposure to cold, the affection
generally progresses to a third stage. Exudative Nephritis.

The transition is marked by the appearance in the urine

1 64 Mary Putnam Jacobi

of still another morphological element — casts or cylinders of
various forms.

We have seen that certain extremely pale, finely granular
cylinders, about equal in diameter to the cavity of the uriniferous
tubes, still invested with epithelium, may be observed in the
urine in health, and are supposed by Robin to be formed of
mucine. But the hyaline casts are quite transparent, and with
firmly defined outline. They are of small diameter, and mingled
with casts covered with epithelial cells, and others whose surface
is moderately granular, attesting the crumbling away of the dis-
integrated epithelium. These casts may be present at the first
examination of the urine, the affection having begun with greater
intensity, and advanced rapidly to the exudative stage. In this
case the illness has been ushered in with chills and shivering, not
very intense, but general and prolonged. The chills are followed
by fever, pain in the lumbar region of the back, vomiting, violent
headache. Drowsiness is a frequent and characteristic symptom,
of great value in distinguishing between the acute nephritis and
other febrile affections, especially small-pox at the initial stage,
where pain in the loins is a symptom even more noticeable than
when the kidneys are the seat of disorder. The urine diminishes
notably in quantity, and at the beginning its specific gravity may
even be increased, as in other phlegmasias and fevers. The re-
duction of water is more rapid than the reduction of urea, so
that the proportion of solids may seem relatively increased,
although they are absolutely diminished. In a few days, how-
ever, the impairment in the cell functions becomes manifest, and
the specific gravity of the urine falls from diminution in the
elimination of its solid materials. Micturition is frequent, owing
to reflex irritation of the bladder. The urine contains blood in
various proportions, as previously noticed, and is strongly
albuminous — sometimes becoming nearly solid on the addition of
nitric acid. CEdema is rapidly formed and extended, constitut-
ing the most conspicuous phenomenon of the group, and which
has procured for it the title of acute dropsy. Interpretation of
the real significance of the casts found in the urine is of consider-
able importance, since upon it has been made to depend the
theory of the renal lesion of which they are sjinptomatic. Ac-
cording to Frerichs, these casts consist of fibrine, exuded from
the blood-vessels under circumstances analogous to those of any

Letters to the Medical Record 165

parenchymatous inflammation, and coagulated in the cavity
of the uriniferous tubes, upon whose form they are moulded.
Frerichs designates the lesion, therefore, as marking the exudative
period in albuminous nephritis, and Virchow calls it Croupar
Nephritis, the analogue of pneumonia.

Grainger, Stewart, and Dickinson follow Frerichs in this
interpretation, and Traube observes that the variations of
pressure in the blood-vessels constitute a regular scale, of which
the first degree determines the transudation of albumen, the
second fibrine, and the third ruptures them, causing the effusion
of the blood itself. In hsematuria, without casts, it is the capil-
laries in the Malpighian plexus that are ruptured, while the
larger vessels surrounding the tubes resist the pressure. Later,
these allow the transudation of fibrine, and finally may them-
selves give way in totality, causing haemorrhage much more
abundant than in the first case.

But Comil and Rindsfleisch declare that these casts do not
present the reactions of fibrine, and are formed by a colloid
secretion from the epithelial cells, or from the debris of the cells
themselves, agglutinated together. In this view they are ana-
logous, not to the exudation of parenchymatous inflammation,
but to the mucous secretion which accompanies the epithelial
proliferation on inflammed mucous membranes. Hence Cornil
resumes this exudative affection, with that characterized by the
desquamation of epithelium, under the common title. Catarrhal
Nephritis; and Dickinson, in the same way, classes them to-
gether as the several modes of Tubular Nephritis.

No special justification is required for the term inflammation
as applied to these lesions. The entire range of pathology may
always be ransacked at any moment that it becomes necessary
to define a lesion as inflammatory. To avoid this excursion, it
may here suffice to adduce the pain, fever, exudation, and prolifer-
tion of tissue (epithelial cells), as the assemblage of characters
whose ensemble is usually defined as inflammation. The terms
Parenchymatous Nephritis, Nephritic Albuminuria, are applied
by the best modem writers in virtue of this well-founded
analogy.

By extension, however, the same term is retained, when the

' The term croupal is used by German pathologists to characterize inflam-
mation attended by fibrinous exudations.

1 66 Mary Putnam JacobI

only character of inflammation present is the proliferation of
tissue. And this frequently occurs.

For although epithelial casts are constantly present in acute
febrile albuminous dropsy, the converse is by no means true.
The disease, although clearly traceable to exposure to cold, may
creep upon the patient silently and insidiously, manifesting itself
by slight oedema about the ankles and puffiness of the face, with-
out any fever, lumbar pain, difficulty of micturition, or unusual
appearance of the urine calculated to fix the patient's suspicion
upon the kidneys as the seat of disorder. Chemical and micro-
scopical examination of the urine, however, discovers it to be
decidedly albuminous, and containing blood-corpuscles, free
epithelial cells, hyaline casts, and epithelial cylinders. Or these
latter may succeed to simple albuminuria, without any exacer-
bation of the general symptoms. In this case it is probable that
the desquamative and exudative lesions are confined to a com-
paratively small number of tubes, and are insufficient to excite
the nervous disturbance upon which pain and fever depend.

In other cases, these seem to be escaped in virtue of the
unusual extent of the tubular obstruction, which, by interfering
with the elimination of urine and urea, determines a drowsy,
apathetic condition, in which the sensibility and capacity of
reaction are equally diminished.

The frequent succession of the foregoing alterations in the
composition of the urine indicates the frequency with which one
kind of lesion of the vascular element of the kidney may be fol-
lowed by another kind of lesion of the glandular. The possibility
of the sequence is fully established, and our second question
answered before our first. To establish the necessity of this
sequence is not so easy, because so many cases of albuminuria, in
which the urine is loaded with epithelial cells and casts, do not
come under observation until long after the debut, and have been
ushered in by no acute febrile attack, or even congestion
sufficiently violent to notably affect the color of the urine. All
analogy shows, however, that congestion sufficient to greatly
modify the nutrition of a part, and determine the proliferation of
its epithelium, may be insufficient to cause the rupture of the
blood-vessels. The supposition, so widely admitted, that the
hyaline cylinders are formed of coagulated fibrine, exuded from
the blood-vessels under increased pressure, necessarily implies

Letters to the Medical Record 167

congestion as the mechanical condition of their formation. The
theory of cell-secretion implies it by analogy, as the vital condi-
tion of increased activity. Finally, although the delicate
Malpighian plexus probably ruptures under this amount of
pressure, resisted by the tubular vessels, the exudation in the
tubes may be sufficient to prevent the escape of so minute a
quantity of blood, or only permit the gradual filtration of the
blood-corpuscles. Dickinson relates a remarkable case of acute
desquamative nephritis, supervening after scarlet fever, in which
the tubes were so completely blocked up as to cause the nearly
total suppression of urine, and entirely prevent the passage of
blood, although, after death, the kidneys were found in a state of
intense congestion. The writer justly observes, that in severe
cases of this form of disease the absence of heematuria is a much
more dangerous sign than its presence.

From these considerations, therefore, and in the absence of
any direct proof to the contrary, we may presume that the
sequence between vascular congestion and catarrhal nephritis, or
rather the dependence of the latter upon the former, is not only
possible but necessary. Congestion may stop short of desquam-
ative nephritis ; but this always originates in some degree of con-
gestion— a fact that confirms the infiammatory nature of the
desquamation.

If the symptoms progress in severity, or simply present
induration, the morphological analysis of the urine is nearly al-
ways complicated by the appearance in it of fat globules. Their
further description must therefore be confounded with those
characteristics of the

3d Class — Fatty Degeneration, etc. The pathognomonic sign
of fat deposit in the uriniferous tubes, is the presence in the urine
of fat globules contained in epithelial cells or studding granular
cylinders. We have already alluded to the circumstances which
must be taken into account in a diagnosis based upon fatty urine.
It is only when the epithelium containing the fat is shrivelled and
granular, when the cylinders are not too black, and the free oil
globules not too abundant, that the fat can be referred to that
condition of the kidney known as fatty enlargement. The
possibility of( sequence between congestion, catarrhal nephritis,
and fatty degeneration, as manifested by the successive appear-
ance in the urine of blood, epithelial cells and casts, and fat

1 68 Mary Putnam Jacobi

globules, is as well established as that between congestion and
desquamation. All authors relate cases in which, after an acute
attack of albuminuria and dropsy, ushered in as described
above, the epithelial casts are replaced by hyaline tubes studded
with fat, the blood disappears from the urine at the same time the
febrile symptoms subside, the albuminuria and dropsy may
diminish, the patient considers himself well. After an interval
of some months, during which he complains of nothing but lassi-
tude, and perhaps frequent vomiting, the patient's illusions are
destroyed by a renewal of the dropsy, suddenly, after fresh
exposure to cold — or establishing itself gradually and insidiously.
The characteristics of the urine in these cases are the same as
in the catarrh, with the addition of fat. It is diminished notably
in quantity and in specific gravity — the latter corresponding to
the diminution of urea. The dropsy is extensive from the
beginning of the disease or of the renewed attack and death
most frequently results from effusion, in order of frequence, into
the cellular tissue, the peritoneum, pleura, or pericardium.
These symptoms result, as in the case of simple desquamative
catarrh, from the blocking up of the uriniferous tubes, in this
case by an agglomeration of granular and fatty granular masses,
crumbling cells, and cylinders of all varieties. Whenever — by
means of powerful diuretics — a stream of urine is sent through
the embarrassed tubes, the dropsy diminishes.

The same series of chronic symptoms, as we have remarked in
the case of catarrhal nephritis, may develop themselves insid-
iously from the beginning; after months of ill health vaguely
defined, or in the course of some chronic disease, oedema of the
ankles may appear, and examination of the urine detect albumen,
epithelium, and fat. But fat is never discovered during the first
days of albuminous dropsy occurring after exposure to cold, etc.

On the other hand, we have seen that all cases of desqua-
mative nephritis present an admixture of fat globules in the urine
after a period of varying duration, and the general symptoms
characteristic of this lesion cannot, after a certain prolongation,
be distinguished from those of fatty enlargement. It is certain,
therefore, that fatty degeneration may result from a destructive
process consequent upon desquamative nephritis.

According to a theory once professed by Johnson as exclusive,
and still retained by this distinguished writer as applicable to at

Letters to the Medical Record 169

least a certain number of cases, the fatty degeneration of the
epithelium is the initial lesion of a peculiar affection, distinct
from inflammation, and originating in "an unsuccessful effort of
the kidney to eliminate a superfluity of fat from the system, and
the consequent fatty infiltration of the glandular cells." This
infiltration — occurring as we have seen in the course of chronic
diseases, when the fat left unappropriated by the slackened
nutritive processes has a tendency to deposit itself temporarily in
the epithelium all over the body — should explain the frequency of
Bright's disease as a secondary affection.

But, on the one hand, this fatty infiltration differs distinctly
from the degeneration, both in its anatomical characteristics and
the symptoms to which it may give rise. The infiltrated epithe-
lium is normal and perfect in structure, the oil globules are large,
abundant, and distinct, — the outline of the cell firmly defined,
the nucleus generally visible, — and there is no sign of the
granular tumefaction — the "cloudy swelling," characteristic
of cellular disease. The same peculiarities may be observed in
the fatty epithelium that finds its way into the urine, where it is
only present in small quantity, entirely disproportioned to the
amount of fat deposited in the uriniferous tubes and unaccomp-
anied by fatty granular casts. The amount of desquamation
that takes place under the influence of the fatty infiltration
only slightly exceeds that of health, and the vitality of the
epithelial cells is not seriously injured by the deposit. This may
also be completely absorbed, as from other epithelium, and Beer
has observed the renal stroma, especially the angular spaces left
between the conjunctive cells, entirely filled with fat globules,
presenting appearances similar to those of the fat globules in the
intestinal villosities during digestion.

"Within certain limits," observes Dickinson, "fat appears to
be a temporary inmate of the epithelial cells."

On the other hand, the disease most influential in determining
fatty infiltration — tuberculosis — has no marked connection with
Bright's disease; indeed, Dickinson, after numerous autopsies,
declares to have observed even a sort of antagonism between them.
Conversely, the affections unanimously recognized as cau-
sal conditions of the morbus Brightii — valvular disease of the
heart, gout, alcoholism, pregnancy, or syphilis, scrofula, sup-
purating osteitis — ^tend to produce these amyloid degeneration,

170 Mary Putnam Jacobi

those interstitial nephritis, and have no influence in the form-
ation of the large, smooth mottled kidney of fatty degeneration.
It is probable, therefore, that Johnson's theory reposes on an
inaccurate connection between facts, each in itself accurately
observed, — fatty infiltration of the kidney, passage of a certain
amount of infiltrated epithelium into the urine, — development of
Bright's disease in the course of chronic extra-renal affections

P. C. M.

SOME DETAILS IN THE PATHOGENY OF PYAEMIA
AND SEPTICEMIAS

REMARKS BEFORE THE MEDICAL LIBRARY AND JOURNAL ASSOCI-
ATION OF NEW YORK.

As I understand the object of this Association, it permits its
younger members to submit the questions that may have especi-
ally interested them, to the judgment of others older and more
experienced than themselves. This is why I venture to make
some remarks on a subject, which a rather prolonged sojourn in
the hospitals of a great metropolis has forced most prominently
upon my own attention.

The study of putrid and purulent infection, though it orginate
in the province of the operative surgeon, immediately rises into
the sphere of general pathology, and touches upon problems of
the keenest interest to the physician. Moreover, by a singular
fatality, the methods adopted to remedy the effects of accidents,
expose to many of the same dangers as the accidents themselves ;
and operations for many diseases of internal origin accumulate
upon the unfortunate patient the additional perils of an external
traumatism. Finally, while men are more especially exposed
to the superfluous traumatisms of war, women are compelled
to incur the inevitable tratmiatism of childbirth; and the ulti-
mate danger is in many cases the same.

To judge by certain assertions, one might suppose that this
danger had been so much diminished by appropriate treatment,
that it now presented no more practical interest than that of the
plague. The admirers of Professor Lister have far surpassed his
own confidence in the virtues of carbolic acid. In the Dublin
Quarterly for 1869, Mr. McDonnell aflirms that treatment by

' Reprinted from The Medical Record, 1872. VII, p. -j^.

171

172 Mary Putnam Jacobi

Lister's method has attained perfection; and that when a wound
has been dressed with carboHc acid, and its arteries secured
by torsion, it is almost certain to heal easily, while the temper-
ature of the body does not rise above ioo°. Lister himself,
in his famous paper published in the British Medical Journal for
1 867, is not so sanguine. He gives no statistics, but observes that
since the employment of carbolic acid for the dressing of wounds,
his wards, formerly the most unhealthy in the Glasgow infirmary,
have become comparatively healthy, and that he no longer dreads
as before, the advent of compound fractures. In St. George's
Hospital Reports for 1 868, Mr. Holmes gives the result of experi-
ments made with carbolic acid in forty cases. Lacerated wounds
and abscesses did remarkably well under this treatment; all
recovered. Of eight cases of compound fracture, four recovered
and four died — two of pyasmia, one of tetanus, one, on fourth day,
without metastatic abscesses, the case being complicated with
renal disease. Mr. Holmes had twelve cases of incised wounds
and operations, including two amputations of the breast, but only
two involving section of the bones. One of these was a Chopart's
amputation of the foot ; patient recovered after an attack of ery-
sipelas; the other, an amputation of a metacarpal bone, followed
by death from pyaemia. In this case the patient had diseased
kidneys.

In the last October number of the Archives de Medecine, Dr.
Labbee reviews the English statistics, and points out that, even
in Lister's wards, the results of carbolic acid treatment are much
less brilliant than was at first supposed. Thus, previous to this
treatment the deaths after amputations were 41 to 126, or i in 3;
after its adoption, they were 30 in 80 cases, or i in 2.6. During
the last six months Dr. Labbee had extensively employed carbolic
acid, with the most scrupulous attention to the details insisted
upon by Lister, and nevertheless nearly all his amputated
patients had died. This lugubrious statement corresponds
entirely with the facts that I have had an opportunity of observ-
ing closely. For at least three years the use of carbolic or phenic
acid has been almost universal in the great surgical wards of the
Paris hospitals ; but the mortality has not been notably modified,
and remains higher than that of London.

These remarks, with no pretension to statistical value, are
merely intended to show that the antiseptic treatment is by no

Pathogeny of Pyaemia and Septicaemia 173

means infallible. The phenic acid of the modems is not a pana-
cea, any more than the famous sage of the ancients. It follows
that the doctrine upon which its employment is based, is not
sufficiently comprehensive to include all the cases to which it is
applied. This doctrine is sometimes announced in a proposition
that rather unfairiy combines the opinions of Roser on miasms,
and of Pasteur on animal germs. It is sometimes said that these
germs constitute hospital miasms, and act either directly, being
themselves absorbed into the blood, or indirectly, after having
determined the putrefaction of traumatic fluids. The absorption
of fluids thus putrefied is sufficient to account for the most various
surgical accidents — phlebitis, erysipelas, pyaemia, septicaemia,
hospital gangrene. In virtue of the assumed unity of their
aetiology and of their nature, these several affections are asserted
to be equally amenable to a single mode of treatment. This
consists in the destruction of animal germs, first in the atmosphere,
by purification of the air; second, upon the wound itself, by dress-
ings with carbolic acid.

But, in the first place, the animal germs to which Pasteur
attributes the mechanism of putrefaction do not exist merely in
impure air, but even in tolerably pure air, unless it be absolutely
free from animal or vegetable dust — such air, indeed, as may be
brought from the summit of Mt. Blanc. To prevent putrescible
substances from putrefying, it has been shown necessary to seal
them hermetically, so as absolutely to exclude air. Donn^
experimented on an egg, which he carefully enveloped in cotton
wool, and then obliquely pierced by a knitting-needle, previously
heated to destroy any germs that might be clinging to it. By
means of this puncture air was admitted to the interior of the egg,
but only after having been filtered by the passage through cotton.
The egg putrefied, as it will not do if it be covered with an imper-
meable varnish. But Pasteur asserted that the precautions
taken had not been sufficiently severe; that it was possible to
admit some of these ubiquitous infusoria during the manipulation
of the experiment. How much more, then, in any wound not
treated by absolute occlusion !

In the second place, the researches of Bechamp and Estor,
communicated to the Academic des Sciences in 1868, indicate
that, though the access of air be essential to putrefaction, yet the
presence of bacteria in animal putrefying substances does not

174 Mary Putnam Jacob!

depend on their introduction from without, but on the develop-
ment of germs already contained in the elements of the tissues
themselves. Especially in the cells of the liver, both in man and
in other animals, these observers have discovered certain spheri-
cal granules which they call microzymes. These remain spheri-
cal as long as the organ is in health, and constitute a normal
necessary part of its elements. But when the tissues are separ-
ated from their vital connections and exposed to the air, these
granules at first arrange themselves in strings, and finally assume
the shape of moving or motionless rods, presenting all the appear-
ance of the vibriones known as bacteria and bacteridia, and des-
cribed by Davaine. ^ Fragments of liver placed in water contain-
ing either sugar or starch, showed a development of bacteria in
twenty-four hours. But if immersed in ordinary water, the
development was delayed five to thirteen days. Further, what is
extremely important to notice, the addition of creasote or of
phenic acid in no wise affected this proliferation of animal germs,
unless it were made in a quantity sufficient to coagulate animal
tissues. That these bacteria came from the microzymes into
which they were seen to grade, and not from the surrounding
air, seems proved by the fact that they were always discovered in
the fragments of tissue before they appeared in the water in
which these were immersed.

In the Quarterly Journal of Microscopical Science for last
October, Burdon-Sanderson has shown, by most careful experi-
ments, that the microzymes never come from the air. According
to this writer, they frequently abound in water, so that a drop
or two of ordinary spring water added to a test solution is suffici-
ent to determine in it the development of microzymes and of
bacteria. But if the water so added be boiled and the whole
placed in a glass that has been superheated, no microzymes will
appear, even though the liquid be left exposed to the air. In the
latter case, however, torula-cells appear in as great abundance as
if the liquid had not been boiled. It is thus shown that no con-
nection exists between the microzymes destined to develop into bac-
teria and the torula-cells that multiply into fungi. The air is
charged with these latter, while the former abound in animal
and vegetable solids and fluids.

To test the influence of bacteria, apart from that of the morbid

^ DicHonnaire des Science Medicates, Art. "Bacteries."

Pathogeny of Pyaemia and Septicaemia 175

fluids with which they were associated in Davaine's experiments,
Leplat and Jaillard^ injected the veins of animals with fluids con-
taining bacteria obtained from decomposing vegetable infusions.
Such injections were productive of no inconvenience whatever.
Analogous experiments were made by J. G. Richardson, as re-
lated in the American Journal of Medical Sciences for July, 1868,
p. 291. He swallowed from one to four fluid ounces of water,
rendered putrid by two or three days' contact with meat, and
swarming with vibriones. A drop of blood drawn half an hour
after the ingestion of one fluid ounce, presented only a single
vibrio. But with a larger dose and an hour's interval the number
greatly increased. Twelve were seen in as many minutes, and at
one time there were three in one field. In two hours, however,
these had entirely disappeared, their presence in the blood having
occasioned no other inconvenience than slight headache, furred
tongue, and some diarrhoea.

Thus, left to themselves in contact with healthy living tissues,
vibriones are rapidly eliminated without causing any damage.
Moreover, as Davaine observes, in a medium composed of sub-
stances in full putrefaction, these animalculae are also unable to
sustain life. They live upon organic matter that is just begin-
ning to decompose; they cannot determine the decomposition of
living tissues; their germs cannot develop to the potency of
bacteria unless they have free access to oxygen; finally, when the
organic matter in which they are imbedded is dead, and resolved
into inorganic elements, the vibriones die too. Hence, though
Feltz and Cohn have discovered them in the fluids of putrefying
wounds ; though Ranvier has found them near the seat of a frac-
tured bone affected with osteo-myelitis ; though he has further
found germ-granules in metastatic abscesses, — yet, these marvel-
lous little organisms cannot be rendered directly chargeable for all
the accidents of putrid and purulent infection; nor their de-
struction be considered an assurance of security against these
formidable complications of wounds. For, ist, in air that has
been sufficiently purified to avert certain forms of disease, as
hospital gangrene and the more malignant kinds of septicaemia,
the germinal matter of vibriones is still found in considerable
abundance, so that animal fluids or tissues exposed to the air
necessarily decompose.

' Comptes Rendus de VAcademie des Sciences, 1867.

176 Mary Putnam Jacobi

2d. Positive experiments have shown that bacteria by them-
selves, though introduced into the blood, are not injurious.
Further: Bergmann has shown that the dried residue of pus re-
tains its toxic properties, though it have been heated to 212°,
or treated by alcohol of 96 per cent.; and either procedure is
accounted sufficient to destroy animal germs.'

The above-quoted experiments of Burdon-Sanderson tend to
show that the vibriones of the air, which are a cause of putre-
faction, differ essentially from the microzymes of animal fluids,
whose development may be only an effect. But the develop-
ment of these latter to bacteria may act like that of all other
vibriones, in favoring putrefaction. Hence the accession of air
to a wound would work in two ways : it would admit atmospheric
germs, demonstrated agents of putrefaction ; and it would furnish
the oxygen requisite for the development of microzymes, probable
agents of putrefaction. The one and the other class of vibriones
— innocuous if themselves absorbed — only act by determining
the alteration of traumatic fluids ; and these once altered become
toxic, though the causal germs be excluded or destroyed.

That the accidents resulting from wounds depend upon the
introduction into the economy of substances formed upon them is
shown : (a) because the artificial introduction of these same sub-
stances, by injection into the veins, is followed b}^ the same symp-
toms as occur spontaneously when they are left long in contact
with living membranes; (b) because direct experiment proves
that the capacity of absorption from the surface of wounds is
very great.

Two great classes of infection may be formed: ist. That
which depends upon primary absorption from the wound previous
to the growth of granulations or the formation of pus; 2d. That
which supervenes after suppuration, and the complete disappear-
ance of traumatic fever. The first class constitutes septicaemia;
the second, pyemia, or purulent infection.

It is noteworthy that septicaemia is developed at a time
when absorption from the wound is slowest; pyaemia, when it has
begun to be most active. Demarquay has shown that an iodic
solution placed on a recent wound will be absorbed in from fifteen

' On this last point, however, there is at least room for doubt, since
Wyman's experiments {Am. Jour. Set., 1867) have shown that certain infus-
orial germs will retain their vitality even after four hours' boiling.

Pathogeny of Pyaemia and Septicaemia 177

minutes to an hour. But after application to a granulating
wound, iodine may be detected in the urine and saliva in ten,
eight, six, or even four, minutes. It would seem, therefore, that
the accidents of septicaemia depend on the absorption of some
substance more diffusible than that which is the origin of pyaemia,
since it acts more quickly, though at a time when absorption is
less active.

The wounds in which pure septicaemia originates may affect
exclusively the soft tissues. Thus, in wards where pyaemia was
the most frequent disease, I have seen septicaemia develop as a
consequence of an operation for a double prolapsus of the uterus
and rectum, where an attempt was made to extend the perinaeum
backwards by a suture that should include a part of the enor-
mously distended anal sphincter.

Septicaemia is frequent after operations for strangulated
hernia or the extirpation of tumors, and often complicates the
peritonitis occasioned by ovariotomy. But in wards where
pyaemia and septicaemia were both endemic, I have been struck
with the exemption of patients who had suffered amputation of
the mammary gland. On the other hand, the extirpation of a
fibro plastic tumor from the deltoid muscle was followed by a
typical development of septicaemia. The traumatic fever set in
within twenty-four hours after the operation, and, instead of
abating, persisted, and gradually rose into all the violence of the
septicaemic fever.

This form of surgical fever is frequent as a consequence of
diffused acute phlegmon of cellular tissue, even when this is
unaccompanied by osteo-myelitis. It constitutes those pecu-
liarly malignant forms of puerperal fever where death super-
venes with great rapidity, and where, after death, the uterus
presents no trace of phlebitis or of lymphangitis. These cases
are exceptional.

It is a very remarkable circumstance that gunshot wounds, so
excessively dangerous when they affect the bones, are so fre-
quently innocuous when confined to the soft tissues. I had
abundant opportunity for observing this fact, in the case of num-
erous shell wounds that came under my observation during the
siege of Paris. In wards where acute diffused phlegmons fre-
quently proved fatal by generating septicaemia, flesh-wounds
caused by the explosion of shells healed readily, even though,

178 Mary Putnam Jacobi

as in one case, the victim was a woman six months pregnant, and
miscarried after a triple injury in face, thigh, and leg.

A curious case of impunity, even though the bone was in-
volved, was that of another woman who had been for four years
an inmate of the hospital on account of chronic rheumatism in
shoulder, wrist, and knee-joints, all of which were more or less
completely ankylosed. During the bombardment, a shell
exploded in the hospital ward, and carried off this patient's
right arm about three inches below the shoulder-joint. It
was a very clean amputation, with very slight haemorrhage; and
but little trimming of the wound was needed to make a neat
stump, which was speedily covered by fleshy granulations. Not
merely did the patient escape without any signs of septicaemia or
purulent infection; she even had no traumatic fever. I attri-
buted this remarkable exemption to the pre-existence of chronic
adhesive inflammation, which had rendered the tissues — lym-
phatic, cellular, osseous, and to a certain extent even the veins —
impermeable to the septic material arising from the traumatism.

The behavior of gunshot flesh wounds resembles that of those
made with caustics as compared with those made by the bistoury.
It is not my province to insist upon the practical advantages of
the method so eulogized by Maisonneuve, but their bearing upon
the theory of septic and purulent infection is of importance.
The facts tend to show that tissues killed outright, by chloride
of zinc or the actual cautery, present far less chances of infection
than those that die slowly and, during a long period, offer to
absorption the successive products of their decomposition.
They appear, moreover, to block up the roads of absorption, and
not to afford the media for diffusion constituted by loose diffluent
tissues.

Septic absorption occurs to a greater or less extent whenever
decomposing animal matter is brought in contact with living
membranes, and seems to be independent of the state of the
veins.

The condition of the lymphatics is of much more importance.
For at the time that septicaemia develops, the lymphatics, torn
by the traumatism, gape open into the wound, while later they
are closed by fleshy granulations. Septicaemia, which precedes
the formation of these granulations, likewise, in typical cases,
precedes the formation of pus. This does not normally occur

Pathogeny of Pyaemia and Septicaemia 179

before the third day; and if symptoms of septic poisoning have
appeared previous to its establishment, suppuration may be
indefinitely delayed, or the pus be replaced by a thin sanious
liquid, in which pus-corpuscles are rare. According to Robin,
the decomposition of pus is always a consequence of the general-
ized infection, and not its cause.

As might be inferred from this apparent connection with the
lymphatic system, the full development of septicaemia is often
preceded by a lymphangitis. But it is extremely curious to
notice that, should this lymphangitis be immediately followed
by tumefaction or phlegmon of the nearest lymphatic glands,
or by an attack of erysipelas, the general infection seems to be
averted. I have in my notes three cases of compound injuries
of the fingers, followed by abscess in the axilla, which in one case
had been preceded by a subacute phlegmon of the arm; in an-
other, by the red streaks of superficial lymphangitis ; in the third,
by a probable affection of the deep lymphatics. All these cases
resulted in recovery, in the same wards where patients affected
with quite similar injuries were constantly succumbing with
symptoms of septico-pyaemia. The occurrence of erysipelas
seems also frequently to ward off the graver affection. In two
cases of carbuncle treated by extirpation, the occurrence of a chill,
in connection with a sudden drying and glazing of the wound,
was regarded as an ominous forerunner of septic infection, until
the advent of a local erysipelas unexpectedly changed the progno-
sis. In another case, an operation for strangulated hernia in a
woman was followed by an attack of erysipelas on the face, from
which the patient recovered. She subsequently succumbed
to exhaustion, but never presented either symptoms or lesions of
putrid or purulent infection. These facts, and certain statistics
showing the epidemic alternation of erysipelas with graver
surgical affections, bear testimony in favor of the theory that
ascribes erysipelas to a diffused inflammation of the lymphatics
of the skin, caused by the passage through them of irritating sub-
stances. It is upon this theory that Maisonneuve has based his
treatment of erysipelas by application of a blister directly to the
inflamed surface, for the purpose of drawing off septic material in
a profuse discharge of serosity.

The succession of symptoms in septicaemia generally occurs
as follows: The traumatic fever, instead of abating, persists, or

i8o Mary Putnam Jacob!

abates only imperfectly. The suppuration, that should have set
in on the third day, is delayed; and sometimes the wound becomes
glazed and dry, or points of gangrene appear in tissues that
seemed at first sufficiently vitalized. Sometimes, as was the case
with the patient submitted to a perinaeorrhaphy, a fugitive local
erysipelas appears, to disappear after a few hours. About the
fourth day occurs a single chill, often quite violent, immediately
followed by a notable rise of temperature. By the fifth day
the sutures in the wound give away, and the tissues begin to melt
down into an increasingly putrescent detritus. At the same time
the pain of the wound is diminished, and this local blunting of the
sensibility rapidly extends to the entire nervous system. The
patient becomes absorbed, indifferent, finally agitated and
delirious. The delirium is sometimes muttering, often violent.
The fever is remarkable for its continuance; morning remissions
are slight. Under this continued fever the body emaciates; the
cheeks become excavated, and covered with a dry parched flush ;
the eyes are injected; the tongue and lips retracted and blackened
with fuliginosities ; the whole aspect of the patient recalls that of
typhoid fever, and the occurrence of diarrhoea completes the
resemblance.

The peculiar circumstance about the pathological anatomy
of pure septicaemia is its negative character. There is no trace of
phlebitis, thrombi, or metastatic abscesses. The veins are all
permeable, but filled with diffluent black blood like molasses.
The viscera are nearly all softened and congested, as in typhus.

In artificial septicaemia, induced by the injection of putrid
matters into the veins, there is often diffused pneumonia, or there
may be patches of gangrene in the lungs. The most notable
lesion, however, exists in the intestinal mucous membrane, which
is tumefied, hyperaemic, and softened. This lesion corresponds to
the sanguinolent diarrhoea, which is an invariable symptom during
life, and both lesion and symptom point to an effort at elimination
of the poison by the intestinal tube. That the lesion is so ex-
tremely marked in animals, while it is slight or wanting in human
victims, indicates that the effort at elimination is greater in the
former case than the latter, and helps to explain, therefore, the
greater resistance of dogs to the disease.

Finally, a very notable peculiarity of septicaemia is its variable
degree of intensity — variable as the conditions which may give

Pathogeny of Pyaemia and Septicaemia i8i

rise to it. There is the terrible septicaemia of malignant forms of
puerperal fever, that destroys life in a few days; there are the
much milder forms, that almost invariably occur when decompos-
ing animal fluids are brought in contact with any surface of the
body in such a way that any part of them may be absorbed.
The retention of a piece of the placenta in the uterus will give rise
to all the symptoms of an incipient septic fever, as I had an oppor-
tunity to observe in a case the other day. Nay, even in perfectly
normal conditions, recent accurate observations have noted a
rise of temperature as a general occurrence about twelve hours
after parturition. This phenomenon is precisely analogous to
the well-known traumatic fever, and the elementary conditions
are the same, namely, the contact of decomposing non-purulent
fluids with living membranes capable of absorption.

In these cases, the general disease seems to be directly con-
nected with the wounds, and this, not in virtue of the nervous
shock they have inflicted, but of the decomposing liquids, or of
some element in them, that they place in contact with live animal
membranes. The essence of the general disease lies in the fever,
or rise of temperature; and of all the causes that have been
invoked to explain the rise of temperature in such cases, that of an
acceleration of the molecular metamorphoses of the blood and
tissues is infinitely the most probable. For the fever may be
determined, either, as I have said, by contact with animal mem-
branes of substances themselves undergoing rapid chemical meta-
morphoses, or by an injection of these same substances into the
blood, as in Billroth's experiments.^ In these experiments there
was no chill, but the temperature rose immediately as high as
40.5°C., and other symptoms of septicemia followed, as diarrhoea
and great prostration. Recovery frequently took place. In
some cases, where the amount of injected material had been very
large, death occurred, and then the only visceral lesions discover-
able were diffused congestions, especially of the intestinal mucous
membrane. From these experiments the gravity of septicaemia
is shown to be in direct proportion to the amount of putrid mat-
ters thrown into the blood, although in every case they deter-
mined a rise of temperature. Below a certain limit of quantity,
they could be supported; but above that limit, they occasioned
more violent symptoms, which finally proved fatal. This grad-

^ Archiv fiir Klinische Chirurgie, 1862.

1 82 Mary Putnam Jacobi

ation corresponds to that furnished by clinical experience — to the
immense variety in the severity of septicaemic symptoms, which
are least of all after normal parturition; greater after wounds, and
in proportion to their extent ; greatest of all when, long after the
original shock, new tissues have sloughed by the invasion of
hospital gangrene. There are, therefore, the strongest reasons for
accepting the recent doctrine of Billroth, which interprets trau-
matic fever as a form of septicaemia, and septicaemia as a simple
extension or aggravation of traumatic fever.

This analogy suggests that of numerous other affections in
which septicaemia plays a prominent part, as hospital gangrene,
carbuncle, malignant pustule, typhoid fever, variola, tilcerative
endocarditis, even erysipelas when the effort at cutaneous elimin-
ation has proved unsuccessful. In all these cases the evolution of
the affection seems to be connected with the presence in the blood
of rapidly decomposing substances, whose metamorphoses
accelerate those of the animal tissues, including the blood, and
thus raise the temperature of the body.

It is in virtue of this rise of temperature that septicaemia is
allied to pyasmia ; for the injection of pus into the veins, even when
it produces no other effect, generates fever as intense as that
produced by the injection of putrid non-purulent fluids — fever
which may end in death. In other respects the symptoms and
march of pyaemia are quite different from those of septicaemia.

As every one knows, pyaemia originates most frequently in
some lesion of bones, which places the wounded osseous tissue
in immediate communication with the air. The larger the bone,
the greater the danger, which is most to be dreaded after injuries
of the femur. Who is not familiar with the train of events that,
in such a fatally large number of cases, follows upon an amputa-
tion of the thigh? The patient may have recovered from the
initial traumatic fever, and on the fourth or fifth day be appar-
ently in very good condition. Suppuration, which set in on the
third day, becomes profuse, but the pus remains thick, yellow,
laudable, or only slightly offensive in smell. Thus, suppuration
precedes the invasion of pyaemia, while the symptoms of septicae-
mia generally begin before the establishment of suppuration, or
arrest it if pus be already formed.

The wound is extremely painful, and its sensitiveness seems
to increase instead of diminishing. The process of dressing the

Pathogeny of Pyaemia and Septicaemia 183

wound throws the patient into an agony; but when this is over, he
is comparatively comfortable, often extremely hopeful and
sanguine. One day, generally between the fifth and tenth, the
nurse observes that the patient has eaten less than usual. In
reply to inquiries, however, he asserts, sometimes quite vehe-
mently, that he is perfectly well. A day or two later he acknowl-
edges having had a slight chill or fever, that he refers to only on
account of the persistent questionings of the surgeon. Some-
times several days, even a week, will elapse before the chills are
repeated; sometimes they follow in rapid succession, coming
every day, or even twice and thrice a day. It is extremely rare
that only one chill precedes the invasion of fever; and even then,
this invasion only occurs after a certain interval. The chills are
ver>' apt to return after the establishment of fever, and checker
its course in a way never seen in pure septicaemic infection.

The rise of temperature occurs sometimes after the complete
subsidence of the traumatic fever, in notable contrast with that of
typical cases of septicaemia. It is rarely as rapid, as intense, or as
continued as in the latter case; for some time it presents very
marked morning remission, and only gradually rises into
continuity.

The appetite and strength fail, and the patient is conscious of
his increasing weakness, and complains of it, as is never the case
in septicaemia. Hence it seems much more notable. The skin
and sclerotics assume the characteristic yellow hue, extremely
unlike the red parched flush of septicemia, and analogous to that
of cancerous infection, with which Billroth compares it. It is
one of the forms of jaundice described by Gubler, dependent on a
destruction of red corpuscles in the blood. The tongue of the
patient becomes dry, but never blackened by fuliginosities as in
septicaemia. The intelligence remains clear, but the mind begins
to be darkened by gloomy forebodings, by a semi-consciousness of
the dissolution of vital forces already begun.

During this time the aspect of the wound is little changed,
the suppuration is abundant, according to Billroth is increased,
and my own observations accord with this statement. An exten-
sion of suppuration takes place, as the older writers would say,
and is manifested in one or more of three different ways.

In the first place, cold abscesses may form in different parts of
the cellular tissue, generally of the extremities, sometimes in the

1 84 Mary Putnam Jacobi

more decumbent portions of the trunk. In the second place,
purulent effusions may take place into the articulations, or serous
cavities, and that with extraordinary rapidity. This purulent
arthritis is a very common manifestation of infection during the
puerperal state. I remember one case especially, which I had an
opportunity of observing at the clinique, that might be con-
sidered as a type of this class. The patient had had an attack of
subacute metritis, which was subsiding, when she complained
of pain in her left elbow-joint; and in the course of twenty-four
hours the articulation became evidently filled with liquid, swollen,
extremely tender, but without any inflammatory redness. The
only other symptoms presented by the patient were diarrhoea,
and a certain dulling of the intelligence. M. Depaul immediately
pronounced a fatal prognosis, which was justified four or five da^'-s
later by the death of the patient with all the symptoms of puru-
lent infection.

These external suppurations, however, indicate a com-
paratively curable form of the disease, and, when manifestations
of the infection are confined to the cellular tissue or the articu-
lations, the patient may recover. I have seen three curious
cases of this category. After a compound fracture of the tibia,
a patient was affected with cold cellular abscesses in various parts
of the body, and with purulent effusion into one of the knee-
joints; yet he ultimately recovered.

In another case, also of compound fracture of the tibia,
the patient had had three chills, and an abscess had de-
veloped in the thigh. After the administration of quinine, the
course of the infection seemed to be arrested, and the patient
recovered.

In a third case, the purulent infection had originated in an
anthrax, which had been followed by abscesses in the breast,
glutasal region, and leg, and by an effusion probably purulent, in
the knee-joint. Notwithstanding this multiple suppuration, the
patient recovered, and the articular effusion was reabsorbed
with the rapidity so remarkable in such cases.

These cases recall the experiments of Sedillot upon dogs,
where injection of pus into the veins was followed by the develop-
ment of external abscesses, but finally by recovery.

External suppuration or suppurative inflammation of serous
cavities may, however, of itself prove fatal, as in a case that I saw

Pathogeny of Pyaemia and Septicaemia 185

at the Children's Hospital, where purulent infection is com-
paratively rare. A child four years old had been submitted
to Chopart's amputation of the foot, on account of a fungous
arthritis, accompanied by necrosis of some of the medio-tarsal
bones. The first few days after the operation passed very well;
then secondary fever set in, and was followed by symptoms of
arthritis in both elbow-joints, and of double pleural effusion.
Death occurred about a fortnight after the operation, and at
the autopsy were found abundant purulent effusions in the arti-
culations, in both pleural cavities and in the peritoneum. This
purulent peritonitis had been latent and quite painless, and had
probably taken place during the last days of existence, when
sensibility was blunted. There were no traces of metastatic
abscesses in lungs, liver, or spleen.

These metastatic visceral abscesses constitute the third form
of generalized suppuration, and the lesion most characteristic of
pyaemia. The invasion and march of the disease seems to coin-
cide exactly with their development and evolution. To them is
due the dyspnoea that occurs early in the disease, while that of
septicEemia, dependent on the poisoning of the mass of the blood,
does not supervene till later. The respirations are rarely below
forty, sometimes as high as fifty or sixty. With the progress of
one or the other of these suppurations, the prostration of strength
increases. All the powers of life seem to be gradually dissolved
apart from one another, and drift away separately before sinking
down into the sea of nothingness that is rising to engulf them.
Hence towards the close, a peculiar incoherence of the mental
faculties and of speech, that is quite distinct from the delirium of
septicaemia. The patient will interpolate absurdities in the midst
of a conversation whose general tenor is reasonable; he has tem-
porary hallucinations of vision; he loses all capacity for com-
parison, and consequently for astonishment; his mind resembles
that of a person in the incipient stages of dementia.

This ataxia of the intelligence finally extends to the spinal and
peripheric nervous system; there is carphologia, the wandering
involuntary movements by which the patient seems vainly
endeavoring to clutch at the life that is slipping away from him.
Finally, consciousness is entirely gone — the patient lies on his
back with his eyes closed, already half a corpse. I have seen one
case where this condition was prolonged a month, and Mr. Paget

1 86 Mary Putnam Jacobi

relates similar cases of chronic pyaemia, where, as in Edgar Poe's
story, the patient seems to have been magnetized when at the
point of death, and his dissolution arrested, but left constantly
imminent. It is during this last period that the suppuration on
the wound diminishes.

The autopsy of patients who have succumbed to pyaemia
reveals one or other of three characteristic lesions, and very
frequently a combination of all of them : osteo-myelitis ; venous
thrombi, with or without phlebitis; visceral abscesses, or purulent
effusions into the articulations or serous cavities.

The osteo-myelitis, whose presence might have been inferred
from the constancy with which pyaemia is associated with lesions
of the bones, is extremely frequent. M. Ranvier, in an article
published in the Lyons Medicate for last May, observes that he
found it in all the autopsies made at Val de Grace during the siege.
M. Gosselin, in his clinical lectures, always insisted upon this
coincidence, and has referred to it again in the recent discussion
at the French Academy. I have certainly had abundant oppor-
tunity to observe it myself.

This osteitis is always of the rarefying variety ; the bony tissue
is highly vascularized, and the surface of a section shows the
trabeculse to be red and softened, and the spaces they enclose
enlarged, and filled with grumous sanguinolent matter. The
medtdlary canal is filled with a vascularized pulpy mass, whence
the fat has disappeared, a most noteworthy circtmistance. A
very characteristic detail is the projection of a portion of the
mass from beyond the medullary canal.

Of less importance for the pathogeny of pyaemia is the thicken-
ing of the periosteum, and its frequent detachment from the bone
by neoplastic material formed beneath it.

There are two noticeable facts about a bone in this condition :
1st. That all its cavities, both the medullary canal and the spaces
between the trabeculae, instead of being obstructed by solid clots,
are filled with loose, pulpy, diffluent matter, exactly calculated to
offer a medium of diffusion for liquids carrying solid particles in
suspension. 2d. That the fatty matters of the meduUa, so
eminently adapted to rapid movements of chemical metamorpho-
sis, are as ready for absorption as are the liquids on the surface
of the original wound.

Not only is osteo-myelitis an almost invariable attendant on

Pathogeny of Pyaemia and Septicaemia 187

fatal cases of compound fracture, but it may constitute the sole
perceptible cause of pyaemia, as when the latter supervenes upon
an acute necrosis (so called), or even, under certain circumstances,
upon simple fracture. I have observed an example of pyaemia in
an old man affected with simple fracture of the neck of the femur
which had begun to consolidate when he succumbed to the
affection, at that time endemic in the ward. Billroth quotes a
similar case; and Prescott Hewett records a third in the Lancet
for 1867.

In another instance that I have seen, the pyaemia supervened
upon a chronic otitis, accompanied by caries of the petrous bone.
In all these cases, metastatic abscesses were formed in the lungs.

The second lesion that may be found in pyasmic autopsies is
phlebitis. Billroth observed it twenty-eight times in eighty-four
cases. As is well known, it is to phlebitis that Berard ascribes all
the phenomena of purulent infection. The apprehensions of
danger from this cause have been much diminished since Virchow
has shown that the coagulation of blood in the veins is not its
consequence but its cause, and that irritation directly applied to
empty veins inflames the external coat, but leaves the inner
tunic untouched. The inflammation of the inner coat is always
a consequence of the softening of the coagulum that has formed
in the cavity.

This softening, or suppuration, as it has been called, takes
place in two ways: ist. By the molecular disintegration of the
fibrin. 2d. By the penetration into its mass of pus cells, or white
blood-corpuscles, that have wandered from blood-vessels or from
purulent collections in the neighborhood of the thrombus.
Hueter, in his chapter, in Billroth and Pitha's Surgery, does not
hesitate to admit this penetration, and considers it proved: (a.)
By Cohnheim's experiments on the capacity of white blood-
corpuscles to traverse the walls of capillaries and blood-vessels.
(b.) By those of Recklinghausen, published in the Archiv of
Virchow, and which show the contractility of pus cells, and of
cells of connective tissue, (c.) By the experiments of Bubnoff,
recorded in the Centralhlatt, of 1867, there has been directly
observed the passage into the thrombus of pus cells that had
previously taken up granules of cinnabar. In this connection we
may inquire whether the presence of the granules did not com-
municate a force of impulsion to the cells that they otherwise

1 88 Mary Putnam Jacobi

would not have possessed; and whether, therefore, pus cells that
had become granular by commencing decomposition, would not
be able to penetrate where others were shut out.

When, by the medium of a phlebitis, inflammation may be
propagated from the wound to tissues of vital importance, the
softening of the clot may prove immediately fatal. In the
Archives General es for 1871, Reverdin has pointed out that in
anthrax of the face, inflammation of the facial veins may extend
to the sinus of the dura mater, and excite a fatal meningitis.

Except in such special circumstances of contiguity, phlebitis
remains a purely local affection, not only in such typical cases as
that of inflamed varicose veins, but also in others where it seems
to substitute itself for a general disease. Thus, during an epi-
demic of so-called puerperal fever, the patients affected with a
well-defined metritis, or phlegmasia alba dolens, generally escape
peritonitis or septic infection. Even the phlebitis that seems to
have been generated by transport of pyrogenic material from a
distant wound, may result in recovery, without signs of infection.
I have seen one case where the extirpation, for cancer, of a mam-
mary gland, was followed by phlebitis of the right leg — a real
phlegmasia alba dolens, which retarded, but did not prevent
recovery. So marked is the opposition between local adhesive
phlebitis and pyemia, that Sedillot treated incipient cases of the
latter disease by cauterization over the veins leading from the
wound, for the purpose of exciting inflammation and an effusion of
plastic material that should erect a barrier against the absorption
of putrid substances, or, as Sedillot maintained, of pus.

When the fibrinous coagulum remains hard, and obliterates
the vein, no phlebitis ensues, as may be seen in ordinary varicose
veins, or in the inopexia of cachectic diseases. The inflammation
of the inner coat of the vein, as I have said, only occurs when the
process of softening of the clot has extended the cavity first hol-
lowed out in its centre, to the membrane limiting its periphery.
It is infinitely probable that this process, which causes the phlebi-
tis, is itself the cause of accidents of which the phlebitis is only an
incident, because, on the one hand, these accidents coincide with
the softening of thrombi, when little or no phlebitis exists ; on the
other hand, there are very rarely accidents with a less degree of
softening, and a very intense degree of phlebitis.

The question of the influence of phlebitis in pyaemia resolves

Pathogeny of Pyaemia and Septicaemia 189

itself, therefore, into two others: ist. The formation of thrombi;
2d. Their disintegration.

Now it is extremely noticeable that many of the circumstances
which favor the development of thrombi are precisely those
which seem almost essential to the development of pyaemia. As
Weber observes, since every traumatism involves a solution of
continuity of veins, and since this is necessarily followed by a coa-
gulation of blood in their interior, the formation of thrombi is a
necessary consequence of every wound. But in superficial
wounds of the soft tissues, the vessels are small, and easily obliter-
ated at their extremities. When larger vessels are torn, one of
two things happens: Either the vessel flattens together above the
clot, obliterating its extremity, and then the thrombus never pro-
jects into a free cavity; or the clot is prolonged as far as the near-
est collateral vessel, and its extremity floats free in the stream,
and in a space larger than its own diameter. When this last
occurs in arteries, as is normally the case after hgature, no harm
results, because the stream of blood is not coming from the
collateral, but passing down into it, and if any fragments are
separated from the fibrinous clot they must be carried down to
another point on the periphery of the vascular system. But
in the case of a vein the conditions are reversed; the collateral
current comes from the periphery, strikes the floating end of the
coagulum, breaks off a fragment, and carries it towards the heart
and lungs.

Of the conditions which favor the distintegration of the throm-
bus, the first, therefore, are those which expose its free end to be
broken off mechanically. These conditions are two : length of the
coagulum, and such a structure of the tissue surrounding the
veins as is opposed to their collapse.

The length of the coagulum is increased: ist. By whatever
increases the amount of fibrin in the blood, or render its circu-
lation sluggish, as abundant haemorrhage, exhaustion from
previous disease, privation, or old age. Weber attributes the
rarity of true purulent infection among children to the activity of
their circulation, which restricts the formation of thrombi. 2d. By
the absence of valves in the veins. 3d, By the sudden sup-
pression, through amputation, of an extensive vascular territory.

The two latter conditions are presented by the veins in the
long bones, the last especially after amputation of the thigh,

I90 Mary Putnam Jacobi

where, as is known, the Hability to pyaemia is at its maxi-
mum.

In osseous tissue, and especially in that of the long bones, is
also found the second general condition favoring long coagula,
namely, a structure that prevents the veins from collapsing.
Lining the pores of the bones, they are necessarily maintained dis-
tended, and this circumstance, which has been wrongly supposed
to imply such gaping open into the wound as should permit the
direct entrance of solid particles, really favors the formation
of lengthy coagula, with all their consequences. The same condi-
tion may be presented by the sinuses of the uterus when that
organ fails to contract sufficiently after parturition. Here again
are no "open mouths," but tortuous vascular canals, in which
collateral currents meet and cross each other in every direction,
filled with loose fibrinous clots that offer media for diffusion, and
are liable to disintegration.

The circumstances that favor the disintegration of the clot
throughout its mass, constitute the second class of conditions
which render thrombi dangerous.

1st. First among these is the osteo-myelitis, which we have
already noticed as so generally existing in fatal cases of pyasmia.
The local activity of the circulation, uncompensated by sufficient
force in the central part of the system, on the one hand determines
serous effusions into the clots; on another, creates collateral
currents ready to carry down stream the fragments resulting
from the disintegration. This effect is added to that proper to
the inflammation itself.

2d. The softening of the clot is favored by the penetration
into its mass either of pus cells already effused elsewhere; or of
white corpuscles directly passing from the neighboring blood-
vessels ; or, finally, of putrid liquids. We have noticed that the
penetration of pus cells, which could not in any wise be considered
a phenomenon of absorption, would be probably favored by their
granular and angular condition ; and as this is peculiar to decom-
posing pus, the influence of the latter may be in part explained.
As to the white blood-corpuscles, with which we have seen that a
certain proportion of pus cells may be identified, the most com-
mon condition of their transudation is their previous stasis in
capillaries, which has long been known to be one of the initial
phenomena of inflammation. The well-demonstrated influence

Pathogeny of Pyaemia and Septicaemia 191

of intense local inflammation upon the development of pyaemic
accidents, is thus in part accounted for by the penetration into
the interior of thrombi of pus cells existing in the neighborhood.
When such elements come from the tissues surrounding the
thrombus, they penetrate it in virtue of the contractility demon-
strated by Cohnheim and Recklinghausen. But, if they ever
come from the surface of the wound — that is, penetrate from
without inwards — they are diffused like other solid particles in
the liquids which hold them in suspension.

Since, after the closure of the lymphatics, there are no open-
mouthed vessels gaping into the wounds, and consequently the
absorption of pus as such is impossible, this diffusion from the
surface of the wound is regulated by the general laws of diffusion.
Thus it will be greater when there is a stronger pressure without,
such as may be exercised by tissues rendered tense by inflam-
mation or by fibrous aponeuroses, and when this is combined with
a diminution of the pressure within, as by a lowered tension in the
blood-vessels. A liquid diffuses more easily when it is less dense,
and especially when it contains less colloid or albuminous sub-
stances. Hence the thin sanious fluids first formed on wounds may
be expected to diffuse more readily than thick pus, rich in
albumen; and this corresponds to the fact already noticed, that
septicaemia precedes the formation of pus, and seems due to toxic
substances more diffusible. A granulated condition of the pus
cells may favor their penetration. Finally, according to Sachs,
the protoplasma of cells has a tendency to retain the solid parti-
cles of liquids that diffuse into them, so that these grow less and
less dense as they traverse successive layers of cells. With each
decrease of density, or diminution of solid particles, the diffusing
power is heightened, and the fluids that have once traversed the
outer barrier of tissues, pass with continually increasing rapidity
towards the interior of central canals or vessels. The ultimate
action, therefore, would almost necessarily be exercised by the
fluids.

The fluid invariably present in cases of purulent infection,
and added to the ordinary traumatic fluids generating septicaemia,
is pus. From the numerous experiments that have been made
by the direct injection of pus into the veins, certain facts may be
considered as proved, ist. A single injection of fresh pus causes
a temporary rise of temperature, but no other inconvenience.

192 Mary Putnam Jacobi

2d. This same rise of temperature may be induced by the separ-
ate injection of either pus globules or purulent serum. 3d. The
injection of purulent serum holding inert solid powders in suspen-
sion, will determine the formation of pulmonary ecchymoses and
infarcti if the serum be fresh; of pulmonary abscesses if it be
beginning to decompose; of septicaemic symptoms and visceral
gangrene if it be entirely putrid. 4th. The repeated injection
of fresh pus at inteivals of two or three hours will produce metas-
tatic abscesses according to Sedillot; but according to Billroth,
who repeated these experiments, only a rise of temperature some-
times, external suppurations, and occasionally pulmonary ecchy-
moses. 5th. Finally, the injection of putrid pus will determine
a violent septicaemia, with patches of visceral gangrene, and,
in a concentrated form, is one of the most violent poisons
known. .012 of the dried residue is sufficient to kill a small dog.

The entrance into the economy of pus or of some of its ele-
ments, would seem, therefore, to act in one of three ways: ist.
As a medium for the diffusion of solid particles, which would
block up the capillaries of the lungs, and thus form infarcti,
according to the theory of embolism. These solid particles
could not, however, be the pus globules themselves, because, in
clinical conditions, these could never penetrate into the blood
except in very small quantities, and a single injection of much
larger quantities of fresh pus will not produce such effects.
2d. The pus may be supposed to act by a peculiar alteration of
the blood, such as occurs by repeated injections at short inter-
vals. 3d. Finally, it may act as a putrid fluid, but endowed
with toxic properties of peculiar intensity.

The theory of embolism, invoked for the explanation of
metastatic visceral abscesses, has, as every one knows, been
successfully applied to the pathogeny of cerebral and pulmonary
apoplexies; and there is no need in this place to enter upon its
details. That the ecchymoses determined by the injections of
fresh purulent serum and inert powders, represent the initial
lesion of metastatic abscess, is rendered probable by the frequent
clinical coexistence of the two, together with that of all the
intermediate stages between them. Thus, in an interesting case
of acute pyaemia, laid before the New York Pathological Society
by Dr. Janeway, the lungs, liver, spleen, kidneys, and, extremely
rare circumstance, even the heart, are said to be studded with

Pathogeny of Pyaemia and Septicaemia 193

"minute white spots surrounded by a red areola," evidently
metastatic abscesses. The first stage of such abscesses was
represented in the lungs by numerous nodules of pulmonary
apoplexy; the last, at the apex of the heart, by two small cavities
entirely filled with pus.

But the progress of such infarcti towards suppuration,
which is the characteristic fact of clinical pyaemia, and which is so
difficult to reproduce in experiments, implies the addition of some
other element to that of embolism ; for ordinary infarcti do not
suppurate, but undergo the fatty or cheesy degeneration. In
pyasmia, therefore, either the embolus, or the liquids with which
it is impregnated, or both, must be possessed of peculiar proper-
ties, and to them must be due the lobular inflammation of the
lungs, and the suppuration in which it so rapidly terminates.
This local inflammatory property may be considered identical
with the general pyrogenic action that these same fluids exercise
on the blood, and both depend on the accelerated metamorphosis
of tissue and consequent generation of heat due to rapid chemical
combinations.

Diffused suppurative inflammations are, therefore, un-
questionably the proximate cause of visceral metastatic abscesses ;
and Ranvier, in his recent paper already alluded to, considers
them sufficient explanation, without any necessity for the inter-
vention of embolism. This distinguished microscopist declares
that he never found the small vessels surrounding the abscesses to
be obstructed; but on the contrary, during the ascending period
of the abscess, they were always gorged with blood. These
negative facts prove nothing, however, against the former exist-
ence of capillary embolics, which disappeared in the midst of the
vascular afflux their mechanical and chemico-vital irritation had
determined. At all events, these inflammations which M. Ran-
vier shows to be nodules of catarrhal pneumonia, with prolifer-
ation of epithelium, are very different from the diffused patches
of congestion or gangrene determined by the injection of putrid
matters, whether these be purulent or non-purulent. In the
latter case the effect on the general mass of the blood overpowers
the local effect on special groups of capillaries. The lesions, those
of septicaemia, resemble those of typhus, while the catarrhal
pneumonia of pysemia resembles that induced by injection of
solid powders into the bronchial tubes. The peculiar relations

194 Mary Putnam Jacobi

of the capillary net-work of the lungs to the circulation, net-work
which must necessarily be traversed by any solid particles circu-
lating in the blood; the coincidence in pyaemia, of such conditions
as render the circulation of such particles highly probable; the
almost universal localization of pyaemic abscesses in the lungs
where Billroth found them in seventy-nine out of eight-four cases;
the coexistence of all grades of lesions intermediate, with ecchy-
moses and infarcti, and completely formed abscesses; all these
facts indicate that the first-named mode of the action of pus —
that where it acts as a medium for diffusing solid irritative parti-
cles— is one of the most characteristic, and that which chiefly dis-
tinguishes it from non-purulent septic fluids.

In the second place, the fact that repeated injections of pus
will produce effects that cannot be determined by a single in-
jection, imply that the pus may act by a previous special altera-
tion of the blood again different from that of septicaemia. Ac-
cording to Sedillot, the effect of repeated injections of pus is to
accumulate its corpuscles in the blood, and thus block up pul-
monary capillaries by a peculiar kind of embolism. But this
could not be true in clinical cases, for there the pus is not injected
directly into the veins, but its elements, if they penetrate into the
circulation at all, are diffused gradually in too small proportions
to cause mechanical obstruction.^

Billroth admits a multiplication of the white blood-corpuscles,
and an increased tendency on their part to accumulate in the
capillaries of the lungs, whence the metastatic abscesses. He
thus explains both the excess of white corpuscles noted by
Sedillot, and also the peculiarity of the action of pus, as dis-
tinguished from that of septic non-purulent fluids.

Perhaps it is not too hypothetical to connect this excess of
white corpuscles with the tendency to purulent effusions in the
splanchnic serous cavities and in the articulations. These do not
depend upon inflammation, for that seems rather to follow than
precede them; and they may be reabsorbed with a rapidity un-
known in ordinary purulent arthritis.

When the pus is putrid it acts like putrid fluids, and deter-
mines not pyaemia, but a septicaemia of peculiar malignancy.

' M. Demarquay has recently performed some experiments, considered
to prove that such penetration does take place. See Archives Cenerales for
December.

Pathogeny of Pyaemia and Septicaemia 195

The poison generated in pus, therefore, seems to be much stronger
than that of other fluids.

Having passed in review the notable differences that exist
between septicaemia and pyaemia in regard to their symptoms, the
time and mode of their invasion, their anatomical lesions, and
their reproduction by experiment, we are led to inquire whether
these differences depend upon the operation of different poisons,
or of the same poison operating in different conditions. The
second doctrine is most emphatically affirmed by M. Verneuil in the
recent discussion at the French Academy. He declares that pyaemia
or purulent infection is to be regarded as an accidental compli-
cation of a general disease, septicaemia, which in a mild form, at
least, exists necessarily in the case of every open wound. Septi-
caemia depends upon the absorption of sepsine, generated in the
traumatic fluids; pyaemia occurs when this sepsine impregnates
emboli that, carried to the lungs, form metastatic abscesses, of
which each becomes a new focus of infection.

The term sepsine, invented by Bergmann and adopted by
Verneuil, represents the unknown quantity existing in purulent
or putrid liquids that gives them their peculiar pyrogenic proper-
ties. Great efforts have lately been made to isolate this hypo-
thetical substance. Panum and Hemmer have shown that it
exists partly in the serum of the pus, partly in the filtered globules.
It is not volatile, and cannot be distilled from pus, but remains
behind in the dry residue. An aqueous extract of this residue is
toxic, and, moreover, will diffuse through animal membranes, and
communicate its properties to pure water on the other side. This
diffusibility is an eminent characteristic of the "sepsine," so
called; and in virtue of it Bergmann claims to have isolated the
toxic principle from many others with which it was associated,
including inorganic matters, albuminous substances, and leucine.

Direct experiments with a number of substances, as various
salts of ammonia, sulphide of carbon, solutions of leucine or
tryosine, either produced no effect, or symptoms quite different
from those of septic or purulent infection. With sulphide of
ammonium alone, Weber, who employed much stronger doses
than Billroth, obtained a notable rise of temperature and a septic
inflammation of the intestinal mucous membrane.

Until the toxic principle in the two cases shall have been
isolated its unity cannot be considered proved. In the mean time

196 Mary Putnam Jacobi

the following facts speak in favor of the existence of two poisons
analogous to each other, but not identical.

1st. That non-purulent liquids, holding solid particles in
suspension, do not determine the same lesions as purulent serum
that has first been filtered of its globules and then associated with
inert powders.

2d. That the train of symptoms which occur after the estab-
lishment of suppuration, are not merely different in degree, but in
kind from those which have preceded it.

3d. That pus exercises an action apart from that determined
by its putridity.

4th. When pus is putrid it is a more violent poison than other
putrefying traumatic fluids. Clinically the presence of putrefy-
ing pus is associated with the mixed disease, septico-pyamia, the
most fatal of all surgical affections.

5th. The conditions of the diffusion of pus have been shown
to be different from those of primitive septicaemia.

Independently, however, of the probability of some special
toxic agent in pus, which gives a peculiar character to pyasmia,
the existence of metastatic abscesses introduces new compli-
cations by multiplying the foci of infection. From each abscess
new pyrogenic material is continually being thrown into the
blood, and when the abscess is situated in the lungs, the material
that has been formed there is probably peculiar, on account of the
peculiar exposure to air to which it has been submitted.

The dependence of the characteristic march of pyaemia upon
metastatic abscesses, is shown by the insidious invasion of its
symptoms at this moment of their formation, and by its gradual
intermittent progress in proportion to their successive evolution.
Hence the initial chill after the subsidence of traumatic fever;
hence the increasing violence of the chills as the visceral suppura-
tions become more numerous; hence the peculiar danger of pul-
monary abscesses so much greater than that of even pyasmic
abscesses formed in external cellular tissue.

On the other hand, it is unquestionable that the violence of
pyaemia is not invariably in proportion to the number of pul-
monary abscesses; and that in certain cases where the first
symptoms have coincided with external suppurations, the
abscesses found in the lungs after death are evidently of recent
formation. I have seen several such cases, in which, even though

Pathogeny of Pyaemia and Septicaemia 197

the final catastrophe be attributed to the pulmonary complication,
yet it is unquestionable that pyasmia must have been prior to it.
In these cases it is impossible to avoid belief in the direct action
upon the blood of the elements of pus derived from the surface
of the original wound.

The prophylaxis of septicaemia is more easily attained than that
of pyaemia, because the conditions upon which septic poisoning
depends are less peculiar than those of pyaemia. There is no
special anatomical condition of the wound, such as exists when
bony tissues are involved. The system is capable of tolerating
the absorption of a certain amount of septic material, and when,
from the extent of the traumatism, there is an excess of dead
tissue, this may be removed by surgical interference. The great
indications in the prophylaxis of septicaemia are ist, to prevent
the devitalization of new tissues; 2d, to prevent the exposure of
tissues thus devitalized to the action of infusoria, or animal germs,
the agents of putrefaction.

The first indication is pre-eminently fulfilled by purification of
the air which the patient is compelled to breathe. This is effect-
ual, not on account of any direct action upon the wound, but by
maintaining the nutritive powers of the blood and its consequent
action upon tissues whose vitality is threatened. So long as this
vitality is maintained, the development of microzymes is to be
little dreaded.

The second condition is only completely fulfilled when air is
completely excluded from the wound, and with it, on the one
hand atmospheric germs, on the other the oxygen necessary to
the development of animal microzymes. Air is nearly excluded
when a wound is enveloped in an atmosphere of carbolic acid, and
to such exclusion must be largely attributed the favorable result
of such treatment. Occlusion, either by this so-called "anti-
septic" or by mechanical means, may prevent the decomposition
of traumatic fluids; but when this has once set in, nothing will
arrest it, not even the destruction of the germs which may have
been its cause, as we have seen, these die of themselves in the
putrefying fluids whose putrefaction they have determined.
Hence a treatment directed to their destruction would be worse
than superfluous, if it led to neglect of the great indication in the
prophylaxis of this stage, removal of the traumatic fluids from
beyond the reach of absorbents.

198 Mary Putnam Jacob!

The greater facility with which this removal may be effected
in the case of wounds of soft tissues explains their greater im-
munity from danger, and the far greater success of carbolic acid
in their treatment. The septicaemia that may occur in the course
of such wounds, depends upon the absorption of non-purulent
decomposing fluids, and its intensity is in proportion to their
mass. When the fluids already formed have been carefully
washed away, the use of carbolic acid, that will not, by the
ordinary methods, prevent decomposition, nevertheless restrain
it, and hence reduce septicaemic accidents to a degree of intensity
bearable by the economy. It is in these cases that the effect of
good atmospheric hygiene is so apparent, by preventing the
devitalization of new tissues. The most dangerous degrees of
septicaemia may be averted, and its worst form, hospital gangrene,
be entirely banished from hospital wards.

But pyaemia is connected with much more complicated condi-
tions, many of which are entirely beyond the reach of carbolic
acid. It depends on the presence of a fluid that, once secreted,
decomposes with peculiar facility, seems to generate a poison
of peculiar intensity, and expose the products of its decomposition
to absorption at a moment that the power of absorption is at its
maximum. It has been shown to act, not merely in virtue of
such decomposition, like all putrid fluids, but by a special effect
on the blood, and by a special connection with the thrombi
blocking up the veins surrounding the wound. While the poison
of septicaemia is principally absorbed by the lymphatics, that of
pyaemia passes almost exclusively by the veins, either those in the
bones, or those newly developed in the granulations of the wound.

This poison is therefore contained in inaccessible canals, and
carbolic acid has as little effect upon it as it would upon an abscess
in whose cavity it had been injected and shut up to mix with its
contents. A comparatively minute proportion of purulent
poison is capable of inflicting all the injury possible, so that
great diminution of the mass of toxic material has very much
less effect on the development of pyaemia than on that of septic-
aemia. The control must be complete, or it is useless, and it
must be exercised not merely in the general hygienic conditions
to which the patient is submitted, but still more, over the local
conditions peculiar to the anatomical nature of his wounds.

From this predominance of local conditions, pyaemia is, as

Pathogeny of Pyaemia and Septicaemia 199

might be expected, no exclusively hospital disease. Billroth
asserts that it is as common in private practice as in hospitals,
only when a death occurs that cannot be explained by hospital
miasms, it is attributed to gastritis, or other accidental complica-
tion. Mr. Callender, in the fifth volume of St. Bartholomew's
Hospital Reports, shows that although the mortality of city
patients operated on in city hospitals was higher than that of the
country, yet the mortality of country patients was the same,
whether they were in large city hospitals, in small country
hospitals, or even in average country practice.

It follows that absolute exclusion of air from the wound is
much more important in the prophylaxis of pyasmia than of
septicaemia. The partial occlusion effected by incrustation with
carbolic acid, is often sufficient for wounds of soft tissues. But
for wounds involving osseous tissues, the apparatus employed by
M. Maisonneuve at the H6tel-Dieu is much better adapted.
Most American surgeons visiting Paris have had an opportunity
of observing this method of treatment, but I do not know whether
it has been introduced into this country. The moment that a
limb is amputated, the stump is surrounded by a conical gutta-
percha cap, whose rim fits air-tight to the skin. From the apex
of this cap passes an India-rubber tube that connects with an
aspirating pump. By means of the pump the liquids from the
wound may be drawn off, and discharged by a second tube into a
receiver. During the intervals, the elastic walls of the cap and
tube coming from the wound, fall together so that no air is in con-
tact with the suppurating surface. To dress the wound, the tube
is detached from the pump, and connected with the tube of a bulb-
syringe, in whose continuity is inserted a short piece of glass tub-
ing, so that the operator may watch the stream of fluid he injects
upon the stump, and be sure that no bubbles of air pass over.
The detersive liquids employed are either tincture of arnica or a
solution of carbolic acid. These, injected in a continuous stream
on the stump, are allowed to flow off by a secondary tube, con-
nected with that of the bulb-syringe. In this way the wound
is dressed daily, without the least exposure to the air. The
apparatus may also be used in cases of accidental traumatism,
as compound fracture; but here it may be less efficacious, when
the dead tissues have already been for some time exposed to the
air.

200 Mary Putnam Jacobi

As far as my own observation extended, this apparatus
5delded excellent results, and the principle upon which it is based
seems certainly most rational. I am unable to tell why it is not
adopted in other surgical wards than those of M. Maisonneuve. *

' I found, after writing the above, an account of Maisonneuve 's apparatus
in the fifth volume of the Practitioner.

REPORT OF AN ADDRESS TO THE GRADUATING

CLASS OF THE WOMAN'S MEDICAL COLLEGE

OF THE NEW YORK INFIRMARY^

Woman's Medical College of the New York Infirmary.
— The Commencement exercises of this College were recently
held at Association Hall.

Prof. Mary C. Putnam, M.D., delivered an address upon
the true method in Medical Education. She brought out very
clearly and forcibly the principle that the knowledge which is
really to be of use to the physician must be that gained by his own
observation, not that taken on the authority of books or lectures.
From the beginning, therefore, the student should be taught
to observe, to experiment, and to think, for himself. His chemis-
try should be learned in the laboratory; his histology and physio-
logy by work with the microscope and experimentation on
animals; his diagnosis and therapeutics by study in dispensary
and hospital of actual cases, for which, under proper supervision,
he is made responsible. In this way, and in this alone, would his
practical skill keep pace with his theoretical knowledge ; he would
really know his subject, and not simply know about it. When
called to a case of emergency he would be prepared, at once, and
with a just self-confidence, to bring all his faculties to bear upon
it — would think with his whole body, that had been trained for
this very work, and not be driven in despair to his note-book or
his library. Having once learned the true method of study, he
could never become a routinist, but would hail every new case as
a problem for fresh investigation.

The speaker sketched a plan in which all the medical charities
of our metropolis should be organized in a grand system for the

' Reprinted from The Medical Record, 1872.

201

202 Mary Putnam Jacobi

purposes of instruction. The students of the various schools
would be divided into small classes for clinical work, each class
under the immediate charge of a clinical clerk, and the whole
under a central directory; so that wherever a case occurred of
interest to a special class, the notification could immediately
be given and the opportunity improved.

Contrasting what ought to be done in this direction with the
mode of instruction at present pursued in our schools, the Doctor
characterized our lecture system as an enormous anachronism, a
legacy of the times of mediaeval darkness, when original scientific
study was a thing unknown, and the only fountain of learning was
the wisdom of the ancients; when the business of the medical
teacher was to give epitomes of Hippocrates and Galen, and that
of the student to make and memorize his abstracts of these epito-
mes. Now, fully as we realize the grave deficiencies of our
colleges, we think she has here done them less than justice.
Their professors do not, as a rule, content themselves with reiter-
ating the theories of past centuries, or even of the past decade.
They keep abreast of the times, and give the student the latest
results of investigation, which cannot be found in his text-books,
but must be sought in monographs and journals. True, there
are exceptions, even in our own city; but we claim that they are
exceptions to the rule. For this purpose, then — to announce
the last revision of scientific theory, as well as the newest facts of
observation, and, moreover, to present the grand outlines of a
subject in the vivid and impressive way which no book can
imitate — we hold that the accomplished lecturer has still a most
important place to fill. We agree, however, that every fact must
be made the student's own by practical experiment where this is
possible; that he must be taught to test every theory in the
crucible of his own reason ; and that the lectures are valuable only
as they lead him to do so.

The only reference to the recent change of curriculum in the
Medical Department of Harvard University was the statement
that laboratory work, formerly optional, was now compulsory.
We think the stand taken by this school deserved a more cordial
recognition. Its compulsory laboratory work extends not only
to chemistry and gross anatomy, but also to microscopy and
physiology. Its clinical instruction really deserves the name, the
senior students being expected to diagnosticate cases, prescribe

An Address to the Graduating Class 203

their treatment, and present written reports of them, which are
discussed before a "conference" of the class, presided over by a
professor. This, and other similar features, we remember as
prominent in the course many years ago. Taking the above in
connection with the late gradation of studies through the three
years, and the required attendance on recitations during the
summer, we think the school goes far toward fulfilling Dr.
Putnam's idea. A preliminary examination for matriculation,
and an extension of the term of professional study to four years,
are still, however, great desiderata.

We have touched upon only a few points of this address, which
was marked not more by its suggestiveness than by its earnest-
ness, sometimes rising to eloquence.

ON ATROPINE^

A LECTURE DELIVERED AT THE WOMAN'S COLLEGE OF THE N. Y.

INFIRMARY

1873

Ladies : — In inaugurating this year's course of lectures, I must
first point out to you a certain change that I have made in our
programme; — a change which will cause it to differ materially
from that of corresponding courses delivered at other schools
in this city.

Last year, imitating the system that I believe generally
prevails in this country, the lectures on Materia Medica and
Therapeutics were combined, and both attended by all the stu-
dents, whether these had been studying one, two, or three years.
On this account, students at the very outset of their career were
compelled to listen to accounts of the remedial action of drugs,
that their ignorance of pathology rendered completely unintelli-
gible to them; and, on the other hand, others, preparing to
graduate, were obliged to review details in the chemical and
pharmaceutical history of medicines, when these, in comparison
with the urgent interest offered by their therapeutical properties,
could not but seem dull and unimportant. Moreover, such
students, having passed through no preliminary training, were
plunged immediately into one of the most complex and difficult
studies in the entire range of human sciences — that of the action
of drugs on the living organism in health and disease. A science
that requires as basis a minute and comprehensive knowledge of
physiology and pathology, was thus attacked by persons who as
yet were only furnished with the most slender modicum of such

» Reprinted from The Medical Record.

204

On Atropine 205

knowledge. As a necessary consequence, the true complexity
of the subject was ignored, and knowledge of the action of drugs
resumed in a few bald formulas, whose simplicity, no less than
their rigidity, rendered them entirely insufficient as guides in the
labyrinth of therapeutical problems.

As such system of instruction was illogical I have not hesi-
tated to set it aside, though supported by so much example and
precedent. This year, therefore, the course will be divided into
two distinct sections. The first year students will be invited to
the study of materia medica; to familiarize themselves with the
properties of drugs in their natural and commercial condition;
afterwards to trace them through their various pharmaceutical
preparations, many of which they will have an opportunity of
fabricating themselves. They will learn the origin, the botanical
and chemical classification, the chemical constitution and physi-
co-chemical properties of drugs, before attempting to rise to the
contemplation of their properties in relation to vital organisms.
By this means they will thus: ist, acquire certain knowledge
which otherwise they are only assumed to possess ; 2d, be trained
for the acquisition of other knowledge which they must in great
measure miss, if they have not been previously prepared to
receive it by exercise in simpler studies.

The second and third year students will study, in a two years,
course, the physiological action and therapeutical application of
drugs. As far as possible each proposition will be illustrated by
experiments made upon animals in our laboratory, or by the
treatment of patients selected from our clinics.

I will express the hope that, before long, our school will
accept the standard of Europe, and create a chair of materia
medica entirely distinct from the chair of therapeutics : that, fur-
ther, each of the seven primitive chairs will be divided into an
elementary and an advanced section. Until this is done, all
medical education will remain elementary, and the very concep-
tion of a superior education will continue to be ignored.

I have selected atropine as the first subject of this year's
studies, because the researches that have been made in regard to
it afford a complete type of those that should be pursued in regard
to every reputed remedial agent. It is necessary, ist, to observe
the succession of phenomena produced by such agent after its

2o6 Mary Putnam Jacobi

introduction in a healthy organism; 2d, to analyze each of these
phenomena to its ultimate elements; 3d, to compare the effects
of the drug upon organisms involved in various morbid conditions,
with the results obtained from such analysis.

In the first place, therefore, we have to consider the general
tableau constituted by the physiological effects of atropine . . . ;
and the first phenomenon that demands analysis is the effect of
atropine on the pulse.

There is no doubt that atropine accelerates the pulse. But in
regard to this acceleration we must ask the following questions : —

1st. Is this acceleration immediate or secondary ? According
to Harley and Meuriot, the pulse is immediately accelerated after
the administration of atropine; this acceleration is indeed the first
effect produced. According to Schroff, Posner and Nothnagel,
the pulse is first lowered, and afterwards accelerated. According
to Bezold, the acceleration is immediate after subcutaneous
injection, secondary after ingestion of the poison. In Bezold's
experiments upon guinea-pigs and dogs, an acceleration of from
14 to 48 beats frequently occurred during the first minute, or
even quarter of a minute. In one dog, the pulse rose suddenly
from 80 to 240 beats in a minute. In these cases the atropine had
been injected into the facial or external jugular vein.

Harley's observations are less reliable, because not made until
ten minutes after the injection.

In the three cases where we tested the action of atropine on
human beings before your eyes, we observed a fall of the pulse
within ten minutes. In the first case the patient was a delicate,
lymphatic, but not nervous woman, to whom one-fiftieth gr. of
sulph. atropiae was given by the mouth, the pulse then being at
96, probably from some emotional excitement. In ten minutes
the pulse had fallen to 80, and remained at 80 to the end of an
hour, notwithstanding the occurrence of other symptoms of
atropism, a slight flushing of the face, dryness of mouth and
throat, and very slight dilatations of the pupils. In the second
case the subject was a rather robust woman in good health.
The pulse being at 80, one-fiftieth gr. sulph. atrop. was given by
subcutaneous injection. In seven minutes the pulse had fallen
to 68. In fifteen minutes came a dryness of the throat and slight
giddiness. In twenty minutes the pulse had risen to 104. This
rise may have occurred at fifteen minutes, as at that time the

On Atropine 207

pulse was not examined. In the third case, after hypodermic
injection of ^ grain, the pulse fell in five minutes from 92 to 80,
in 10 minutes rose to 100, in 20, to 104.

You see, therefore, that both these cases contradict Bezold's
statement, that the acceleration is always immediate after sub-
cutaneous injection, and always secondary after ingestion; for
in the cases of injection the acceleration, which was notable, was
preceded by a marked diminution, and in the case of ingestion
the pulse fell, and did not again rise. But in this case the subject
belonged to a class that we shall find, for reasons to be hereafter
noticed, is rather insusceptible to the action of atropine, and
therefore the dose was too small. The other cases, on the other
hand, fairly represent habitual conditions. This initial fall of the
pulse is more certain to occur in human beings than in dogs,
whose cardiac susceptibility to atropine is very great. It is also
to be expected from subcutaneous injection rather than from an
injection into veins. This phenomenon is too transitory to be
of any value therapeutically, but physiologically it is extremely
interesting, in connection with another atropine effect of which we
shall presently speak, — I mean the contraction of the small
arteries.

2d. At what doses does atropine determine an acceleration
of the pulse ?

On this point there is unanimous testimony. The heart's
action is accelerated by small doses, and slackened, on the con-
trary, by large. In guinea-pigs, from 0.0005 to 0.02 accelerated
the heart from 4 to 12 beats in 15''; while 0.05 lowered the pulse
in one case from 70 to 44, in another from 80 to 58. With o.io
the pulse first slackened, then stopped in about a minute (Be-
zold).^ In the horse, with one-twelfth of a grain, there was
acceleration of the pulse 10 beats in 35 minutes; with one-sixth,
acceleration of 24 beats in 1 7 minutes ; with \, acceleration of 56
in 12 minutes: and this was the maximum acceleration obtained.
With I grain it was 42 beats in 12 minutes, and with 2 grains 35 in
15, or 37 in 20. Similarly on the dog, with -gV grain pulse rose
from 120 to 300 in 14 minutes; and -^ and -^V grain produced the
same effect; but with ^ the pulse was 400 at the end of i^ hours.
In man there is said to be an acceleration of 20 to 25 beats with
Y^ or ^V grain; 20-60 beats with ^ grain, 20-70 with :^, and

' Ueber die Physiol. Wirk. des A tropins. Leipzig, 1867.

2o8 Mary Putnam Jacobi

only 30 with ^jV of a grain (Harley). ' Meuriot noticed an acceler-
ation of 84 beats in 90 minutes after an injection of o.ooi . Never-
theless, with toxic doses, the pulse remains extremely frequent
until an advanced period of the coma. In Behier's case, ^ where
an old man of 75 had taken 0.013 of sulph. atropiae, the pulse
was 108 in three hours, at the beginning of profound coma, and
rose afterwards and beat at 120 all night, and until return of con-
sciousness. In a case quoted in Amer. Jour. Med. Sciences for
1866, from Schmid,^ after ingestion of ^ grain of atropia, and
during period of excitement, the pulse was 130. On the other
hand, in the famous case of Dr. Angelo Poma,"" when a profound
coma had set in 2^ hours after the ingestion of f 5 j- of solution
of extract of belladonna, the pulse was extremely slow. In
several other cases of poisoning it is recorded that the pulse was
weak and depressible, though the number of pulsations is not
given. In Lee's cases of poisoning with the analogous mydriatic,
stramonium, 5 the pulse was from 100 to 150 in the two men
patients, who were comatose when treatment commenced; and
140 in the woman, who was in a state of maniacal excitement
resembling delirium tremens. The pulse only sinks immediately
and permanently when injected into the jugular vein, a condition
that evidently is never reproduced in man.

By ingestion or subcutaneous injection, and after the initial
slight fall, the pulse is therefore always accelerated; and this
acceleration, though not in exact proportion to variations of
physiological doses, is excessive in those doses where it will
ultimately or rapidly be succeeded by slackening. (See also
Schroff^ and Meuriot.'') This fact is important to remember, in
interpreting certain details of the reactions of belladonna in cases
of opium poisoning. By it we also test the value of the assertion
made by Lemaitre,^ and supported by another, quoted by him
from Leusana, ' that the effect of atropine upon the pulse is only
shghtly appreciable.

" Old Vegetable Neurotics. London. 1869.

' Union Afedicale. 1863. ^ Klin.

* Gaz. Hehdomadaire. 1863. ^ Amer. Jour. Med. Science. 1862.
6 Schmidt's Jahrhiicher, Bd. 76. 1852.

^ Meuriot. These sur la Belladone. Paris, 1 865.

* Archives Generalei. 1865.
9 Union Medicale. 1851.

On Atropine 209

3. How is the pressure in the arteries affected during the
atropine acceleration of the pulse? Marey has formulated the
following law: — "The frequency of the pulse, or of the cardiac
contractions, is in inverse relation to the degree of arterial ten-
sion." It has been said, on the other hand,^ that Ludwig and
Thiry have formulated another law, precisely the reverse of this :
"The frequency of the pulse increases with the arterial tension."
In both cases the arterial tension is taken as the point of departure,
and its rise or fall declared to be a cause of the acceleration of the
heart's action. This quotation, however, is not quite incorrect.
According to the exposition of Ludwig's views, made in a memoir
of Bezold, ^ and also in another of Pokrawsky, after an increase
of the blood-pressure, the pulse was sometimes quickened and
sometimes slackened. This, whether the increased pressure was
determined directly by closure of the cceliac and renal arteries,
or indirectly by irritations of the spinal cord or splanchnic
nerves. Thus Ranke, who admits that an acceleration of the pulse
takes place when the arterial pressure is increased, observes that
it occurs likewise when this is diminished, but when the force
of the heart is diminished even more rapidly than the resistance
in the arteries. ^

It is evident that arterial tension may be increased, either
when more blood is thrown into the arteries by greater force of the
heart's action or when an obstacle exists to its efHux. An agent
that, like cold, excites the active contractility of the small arteries,
by accelerating the peripheric circulation, necessitates the accler-
ation of the heart's action. The tension of the blood-vessels
rises, but the rise is the consequence, and not the cause, of the
quickened pulse. With any condition that weakens at once the
blood-vessels and the heart, as fever, or the action of certain
narcotics, the tension will be lowered, yet the heart accelerated,
while the vessels are passively dilated. Both the acceleration
and the lowered tension depend on the insufficiency of the cardiac
contractions. With bromide of potassium the small arteries are
completely constricted, the tension raised (?), and the pulse
lowered. With atropine, the arteries are partially constricted,
the tension raised, and the pulse accelerated. Only at the very

' Chauvet De la Circulation Capillaire. Theses de Paris. 1869.

' Untersuchungen ilber die Herz und Gefdssnerven der Sdugethiere. 1867.

^ Lehrbuch der Physiologie des Menschen. 1872.

210 Mary Putnam Jacobi

beginning the pulse falls, and this before any effect has been
produced on the small arteries. The acceleration of the pulse
coincides with acceleration of the local circulation, from the
increased active contractility of the arteries. As this local
acceleration is sufficient to compensate the degree of obstacle
caused by the constriction, the rise of tension cannot be explained
by that, but by the rapidity with which the arterial system is
filled.

In Meuriot's experiments upon man with atropine the
line of ascent in the sphygmographic trace (percussion stroke of
Mahamed') remained vertical, but was not so high as normal.
This would indicate that the arterial tonicity was increased,
while the heart had not lost any of its vigor. At the same time,
the line of descent was not separated by any appreciable interval
from the upper stroke, showing that no obstacle existed to the
efflux of blood into the capillaries. This rise in the tension was
first noticed in 15 minutes after injection of o.ooi. (y^^ gr.) and
had increased in 30 minutes, the pulse quickening at the same
time. In one observation, where 0.012 were injected and the
trace taken in 40 minutes, the vertical up-stroke had fallen still
lower, and there was moreover a rounded summit, as if with this
dose and at this time, the efflux of blood was somewhat obstructed .

When the tension in the carotids was measured in dogs by a
haemometer, the pressure rose with a subcutaneous injection of
from 0.005 to 0.05 sulph. atropine (j-g^ to y^ gr.). This was the
limit within which the pulse rose. With injection of o. 10 (i§ gr.)
the pulse and the arterial pressure fell together.

Similar experiments by Bezold gave similar results. In the
cases already mentioned, where the dose administered caused an
acceleration of the pulse, it generally caused an increase in the
blood pressure also. But in one case (Guinea-pig) this sank from
92 to 72 millimetres during the injection, and did not recover
its original level until 30 minutes after, although the pulse was
slightly accelerated. In another, where 0.30 were injected into
the facial vein of a dog, the pulse rose in I minute after the
injection from 60 to 192; but the pressure in the carotid sank
from 140 to 20. In this curious experiment, the dog was killed
by successive doses of atropine (he received in all 0.80); — arti-
ficial respiration was practised and the abdomen opened. This

' Med. Times and Gaz., 1872.

On Atropine 211

operation generally lowers arterial tension, but in this case it rose
to 30 (having sunk to 5), while the pulse beat 168 times in the
minute.

From these experiments it appears, that with the moderate
acceleration of the pulse during the first stage of atropine the
pressure rises; — with the excessive acceleration of sudden toxic
doses, of coma; — of ultimate paralysis, in a word, — the pressure
sinks. We think that it may be thence inferred, that in atropin-
ism the pulse is not accelerated because the tension is increased,
but that the tension is increased because the pulse is accelerated,
the heart at the same time retaining its vigor, and thus, in a given
Lime, throwing more blood into the arteries. In the paralytic
stage the heart contracts as rapidly, but with great feebleness;
at the same time also there is paralytic widening of the blood-
vessels, so that a double influence exists to lower the tension.
These details are of special interest, in comparing atropinism with
the results of section and galvanization of the pneumogastric
nerve.

4th. Thus we see that the heart's action is accelerated by
atropine in extremely small, i. e., therapeutical doses; that this
acceleration occurs immediately in dogs, after a slight initial
diminution in man, and is accompanied by increased arterial
tension. Upon what does this acceleration depend? The pulse
is accelerated, — ist, when the muscular fibre of the heart is di-
rectly stimulated by a greater afflux of blood, itself determined
by increased respiratory movements.

2d. Similar direct stimulus is felt by the intracardiac ganglia,
controlling the rhythm of the heart's movements.

3d. Acceleration also occurs when the cervical sympathetic or
cervical spinal cord from which it is given off is galvanized.

It is well known that the modus operandi of this influence is
the subject of a famous dispute, to which we have already made
allusion. According to Bezold and Pokrawsky, ^ the influence is
direct, and galvanization of the nerve acts immediately upon
the muscular fibre of the heart to which it is distributed. Accord-
ing to Ludwig and Thiry, the influence is indirect, and dependent
upon variations in arterial tension. Galvanization of the sympa-
thetic or of the cervical cord causes the contraction of whole

' Ueber das Wesen der Kohlenoxyd Vergiftung. — Dubois und Reichert's
Archiv, 1866.

212 Mary Putnam Jacobi

territories of blood-vessels, even those of the mesentery. This
still occurs, when the cord is galvanized, after all the nerves going
from it to the heart have been cut, and according to Ludwig,
in that case the pulse is still accelerated. But Bezold and
Pokrawsky affirm, on the contrary, that in this case the acceler-
ation of the pulse is much less marked than when the nerves are
intact. The contraction of the blood-vessels still occurs, but the
direct stimulation of the heart is wanting. The three observers,
however, it is seen, agree in ascribing a certain amount of acceler-
ation of the pulse purely to the rise of arterial tension determined
by constriction of the blood-vessels — contrary to the theory of
Marey. According to Bezold's theory, if atropine stimulated
the sympathetic in the heart, as it does in the small arteries,
the heart would be directly accelerated, by stimulation of its
accelerating nerves. According to the other theory, any stimu-
lation of the cervical or cardiac sympathetic would merely rein-
force that directly exercised upon the blood-vessels by the local
contact of atropine. The only way to prove a direct influence
upon the sympathetic is to isolate the heart by a section of
the pneumogastric, and then administer the atropine. But the
acceleration of the pulse after this operation is already so great,
that such acceleration as might be produced by stimulation of the
sympathetic would be entirely masked. It is certain that when
atropine is injected after section of the pneumogastric, the
acceleration of the pulse is not further increased.

The constriction of the small arteries sometimes coincides
with an accelerated, sometimes with a slackened pulse. Some-
times, as in Ludwig's experiment, where the cervical cord is gal-
vanized after section of the sympathetic nerves going to the heart,
this constriction seems to be the only cause of the acceleration
of the heart's action, and the acceleration is not very marked.
Sometimes, as after administration of bromide of potassium, the
small vessels are strongly contracted, but at the same time,
the pulse falls. The same coincidence is shown in an ob-
servation of Pokrawsky's. When carbonic oxide gas was in-
jected into the veins or inhaled, the small arteries, stimulated
by blood deficient in oxygen and too rich in carbonic acid, con-
tracted: at the same time, the pulse and tension fell "from coin-
cident irritation of the medulla and vagus."

But the active partial contraction of the small arteries deter-

On Atropine 213

mined by atropine, with increased local circulation, is quite
different from the complete contraction caused by bromide of
potassium or carbonic oxide or carbonic acid gas. If the blood
flows more rapidly at the periphery, the heart must contract more
rapidly. Hence in this way the stimulation of the sympathetic
produced by atropine would be one cause of the acceleration of
the pulse. Whether there is also a direct stimulation of the
fibres going to the heart we cannot consider at present as
determined.

4th. The most powerful means of acceleration of the heart's
action is well known to be section or paralysis of the pneumogas-
tric nerve; after this operation the pulse rises immediately to
double and quadruple its previous speed. Now, the remarkable
acceleration of the pulse that follows the injection of atropine
can only be compared to that determined by section of the pneu-
mogastric. It is also most noticeable in those animals, as dogs,
upon whom section of the vagi produces the most marked
effect on the pulse. The tension rises after atropine, as after
section of the pneumogastric. As already noticed, if the pneu-
mogastric be severed previously to the administration of atro-
pine, the acceleration of the pulse is not further increased, as if
the agent upon which the atropine usually acted had been
suppressed by the operation. Finally, if the vagus be cut in an
animal previously atropinized, galvanization of its peripheral
extremity will no longer produce cardiac tetanus. The electrical
excitability of the sympathetic remains intact. From these
facts, we think the inference' is indeed justified, that atropine
accelerates the heart's action, by partially paralyzing the pneu-
mogastric nerve.

At the same dose, however, atropine, as we have seen, has no
appieciable effect on the respiration. Hence the main trunk of
the pneumogastric nerve cannot be paralyzed, for in that case the
respiration would be interfered with in the ordinary manner.
Moreover, when the atropine is injected into the carotid, and
sent towards the brain, the pulse is at first slackened, until time
enough has elapsed for the poison to be distributed throughout
the body, and reach the heart. But if it be injected in the jugular

I Meuriot, Bezold, Botkin, loci cit. Conclusion contested by Harley;
but it is difficult to see on what grounds. Huseman, on the contrary, indorses
this view.

214 Mary Putnam Jacobi

vein, the acceleration is immediate, and much more marked than
by ordinary subcutaneous injection.

Hence we may infer that the atropine acts upon the cardiac
peripheric extremities of the pneumogastric nerve, partially
paralyzing them ; that this is the first cause of the acceleration of
the heart's action. A second is the stimulation of the sym-
pathetic nerve, possibly in the heart, but certainly in the small
blood-vessels. The circulation in them is more rapid, blood
passes more rapidly to and through the heart, hence directly
stimulated to increased activity. This double mechanism is the
first in which the action of atropine resembles that of fever.
Other similar coincidences are the slight rise of temperature, the
slight increase in the excretion of urea, and the diminution of
secretions to which we have called your attention. '

In speaking of the anaesthetic properties of atropine, it is
necessary to recall Botkin's experiments,- and the inference that
this observer draws from them, namely, that atropine primarily
paralyzes the motor nerves. These experiments were made upon
frogs, and with overwhelmingly large doses, and the influence of
diffusion was not taken into account. In order to exclude this
cause of error, the vessels and nerves of the frog's leg must be
isolated, and a ligature passed round the soft parts so tightly,
that the poison, injected under the skin of the other limb, cannot
diffuse through the cellular tissue, but can only reach the nerve
by the artery. In a limb so prepared, after administration of
atropine, the sensibility is diminished, the motility remains
intact, while on the other leg, where diffusion has taken place,
both are diminished equally. ^ If the ligature embrace not only
the cellular tissue, but also the artery, no effect on the nerve will
follow the injection of atropine. This shows that the poison
anaesthetizes the periphery of the nerves, and not their roots or
the nervous centres. For in this second case, as in the others, it
has full access to these parts, but, by ligature of the artery, fails
to reach the periphery of the nerve. No anaesthesia results,
though this supervenes as soon as the circulation in the limb is
restored.

' In a part of the lecture not deemed necessary to quote.

' Ardrio, Virchow, Bd. 24. •» Result of personal experiment.

On Atropine 215

The peripheric localization of the action of atropine is shown
also by another fact. In a limb under the influence of atropine,
an electrical current directed to the skin (or the extreme periphery
of the sensitive nerves) causes no sensation. If the same current
be directed to the trunk of the sciatic, evidence of pain is obtained.
Moreover, reflex contractions occur, first in the same leg, after-
wards in the opposite limb, showing that the conductibility of the
centripetal fibres is intact.

The motor nerves are only indirectly affected; that is, after
diminution of the sensibility, there is necessarily diminution of
reflex contractions. But at this time, direct irritation of the
motor trunks produces as strong contractions as in a normal
condition.

That the spinal cord is not primitively affected seems shown
by the following experiment : — A ligature is passed tightly around
the body of a frog, so as to separate the anterior from the posterior
limbs. Atropine is then injected under the skin of the anterior
half. At first, irritation of any part of the body produces reflex
contractions ; but as the sensibility of the nerves in the anterior
half diminishes, irritation in this region remains without response.
But irritation of the posterior half still produced contractions in
the four limbs. This shows that the excited motor power of the
cord has remained intact, for it is the only medium of communi-
cation between the part irritated and the parts set in motion.

Upon the voluntary muscular fibre, atropine has even less influ-
ence than upon its motor nerves. With the unstriped muscular
fibre however, it is different. We have seen that by stimulating
vaso-motor nerves, atropine stimulates the contractility of the
muscular fibre in the arteries. According to Meuriot and Orri-
mus, in a rabbit killed after administration of a non-toxic dose of
atropine, the movements of the intestine, always observed when
the abdomen is opened, are exaggerated, and they infer that the
muscular fibre is excited by the atropine. Fleming has come to a
similar conclusion, from studying the action of atropine on worms.
Bezold has observed, on the contrary, that the intestine of the
rabbit remains perfectly still, but this is only after very large
doses.

In regard to the unstriped muscular fibre of the intestine,
as in striped muscle, it is necessary to separate the action of
atropine upon muscular fibre from that upon the nerves, and

2i6 Mary Putnam Jacobi

upon two kinds of nerves, the ganglionic and the splanchnic. In
this connection Keuchel's experiments are very interesting.'
Two cats were selected, similar in size, and in both the splanchnic
nerves were cut before their junction with the solar plexus, and
below the diaphragm. Then one of the cats was poisoned with
0.005 of atropine. Both animals were then killed, and on open-
ing the abdomen immediately after death, the peristaltic move-
ments of the intestine were observed to be increased. If now,
on the cat that had received no atropine, an electrical current
were sent through the splanchnic nerve, this peristaltic action is
immediately arrested, just as the heart's action is arrested by
galvanization of the vagus. ^ But in the cat that had received
atropine, the electrical excitation of the splanchnic produced no
effect whatever; the movements continued. The atropine
therefore seemed to act on the intestine by stimulating the gang-
lionic nerves and disseminated ganglia, which provide for the
dilatation of vessels; and by paralyzing the splanchnic nerves,
which, by tending to contract the blood-vessels, tend to restrain
and tonify the contractility of muscular fibre. The opposition is
analogous to that between the pneumogastric and the sym-
pathetic in the heart, and the action of atropine is similar in the
two cases.

Precise knowledge of the mode of action of atropine upon
muscular fibre is especially important for arriving at a true theory
of its action on rigid sphincters, where it has been so often em-
ployed therapeutically. The usual expression, "Belladonna
relaxes the sphincters," is extremely vague, and conveys several
ideas more or less false, among others, that of paralysis of the
muscular fibre. I would venture to suggest that a sphincter
grown rigid under irritation, e. g., an os uteri during parturition,
is, properly speaking, tetanized. It is a remarkable fact that
tetanic contractions are always the result of a peripheric and
consequently reflex irritation,^ as is well known clinically, and

' Schmidt's Jahrhiicher, Bd. 143.

' As galvanization of the splanchnic is known to contract the blood-
vessels, and as the exaggerated movement of the intestine is known to be due
to the rapid formation of carbonic acid, when the abdominal vessels are
exposed to the air, it seems probable that the movements are arrested because
the supply of blood to the muscular fibre is suddenly diminished.

i Traumatic tetanus, of course. Strychnia tetanus seems to be of a different
nature.

On Atropine 217

may be demonstrated experimentally. In a rabbit upon whom I
had made a hemisection of the spinal cord, irritation of the limb
on the side opposed to the section determined tetanic contractions
in the limb on the same side. But direct irritation of the gray
substance of the cord determined clonic convulsions in the adjoin-
ing muscles and in the limb.

Tetanus is not analogous to normal contractions/ but to
cadaveric rigidity, which occurs earlier in tetanized muscles than
others. In this state the fibre is shortened and broadened, and
as it loses its power to contract in proportion to its shortening,^
really remains passive and motionless, molecular nutrition is
arrested, and the coagulation of undecomposed myosine around
the fibre is considered by some observers, in tetanus as in perman-
ent death, to concur at least with change of electrical conditions in
the preservation of immobility. The whole chain of sequences is
broken when the initial irritation is destroyed. The anaesthesia
of the peripheric nerves determined by belladonna allays this
irritation, arrests the transmission of exaggerated impressions to
the spinal cord, and hence the overwhelming motor excitation
that had been sent from it. At the same time, by quickening the
local circulation the atropine may facilitate the removal of coagu-
lated or waste substances clogging up the substance of the
muscle.

In regard to the mechanism of the mydriasis determined by
atropine, you will still frequently hear it ascribed to a "stimula-
tion of the dilating, radiating fibres of the iris." Even Stellwag,
after adducing a great many facts that speak in favor of another
theory, concludes by ascribing to atropine a double function.
On the one hand it paralyzes the motor ocular nerve, but on
the other it "stimulates the nerves distributed to the muscular
fibre in the dilator papillee, — and also in the coats of the blood-
vessels. ' ' ^ The existence of the dilator is accepted on the author-
ity of Koelliker, Valentin, Merkel; the distribution to it of the

' This fact corresponds to that observed by Legros and Onimus, where
direct irritation of certain parts of the gray substance increased the convulsive
movements in choreic dogs. Also with the clonic convulsions of epilepsy.

' Brown Sequard, Journal de Phys., 1859.

3 Stellwag. Der Intraoc. Druck. Wien, 1868. P. 93.

21 8 Mary Putnam Jacobi

sympathetic nerve is inferred from the effects upon the pupil of
section or irritation of that nerve.

You know that when this section is made the pupil instantly
contracts, and when the peripheric extremity of the severed nerve
is galvanized, the pupil dilates again. The contraction of the
pupil after section of the sympathetic is supposed to result from
paralysis of these fibres, and to the exclusive predominance of the
circular fibres controlled by the motor oculi.

Galvanization of the cervical cord produces as much dilatation
of the pupil as if the current were directed to the nerve itself.
Now galvanization of the cord which is everywhere followed by
contraction of blood-vessels, contracts the blood-vessels in the iris
as well.^ On the other hand, paralysis of the vaso-motor
nerves from section of the sympathetic dilatation of blood-vessels
in the iris, as in the head where the temperature rises, is followed
by visible enlargement of its tissue and diminution of the
pupil.

Stellwag insists on many facts that show a constant associ-
ation between modification of the vascular tissue of the iris, and
changes in the diameter of the pupil. Besides the results of
galvanization of the cervical cord and of the sympathetic quoted
above, he observes that mydriasis is always accompanied by a
tumefaction of the ciliary processes, whose size diminishes during
myasis. In the first case blood is passed out from the iris, in the
second case, it flows back again to it. Ligature of the common
carotid is followed immediately by contraction of the pupil, — an
effect of the irritation of the brain from sudden anemia. But
the secondary result on the eye is dilatation of the pupil, when the
irritative effect has passed away, and the vascular tissue of the
iris finds itself emptied. ' ' Did not such mighty authorities speak
in favor of a special dilator of the pupil, we should be inclined to
believe that the sympathetic was distributed to the walls of
blood-vessels only, and that variations in the size of the pupil were
due exclusively to variations in their diameter. " (Loc. cit. p. 79.)

The suddenness with which the pupil contracts after section
of the sympathetic shows that an effect of irritation precedes the
paralysis of the vessels, which occurs more gradually, though
still rapidly. This sudden contraction is due to a reflex irritation
of the encephalon, propagated thither by the central extremity

' Stellwag. Loc. cit. p. 76.

On Atropine 219

of the sympathetic. It is analogous to that which may be de-
termined by any irritation of the brain, especially of the tu-
bercula anadrigemina, or crura cerebelli, or by the ligature of
the carotid.

The contraction of the pupil is not determined by opposite
but by different influences from that which causes its dilatation ;
it is to be expected, therefore, that it should be expected by
a different apparatus. In all the active physiological func-
tions of the iris, the pupil contracts. For no purposes of vis-
ion does it dilate actively; in obscurity, or in vision of distant
objects, the dilatation is caused by simple relaxation of the
muscular fibre of a sphincter, from which the normal stimulus
had been withdrawn. It is in these cases moderate, and not to
be compared to the widening determined by atropine, or by
galvanization of the cervical sympathetic, an operation which
always constricts the blood-vessels, but only occasionally affects
the retina. Any such effect that is produced is irritative, and
manifested by flashes of light ; hence if the contractility of the iris as
a muscular membrane were called into play at all, it should be to
diminish the pupil, as it does physiologically whenever the retina
is irritated. But the reverse occurs — already a proof that the
dilatation does not depend on the muscular elements immediately
connected with the physiological functions of the iris, but rather
upon its blood-vessels.

Gruenhagen, with less respect for "weighty authorities"
than is manifested by Stellwag, entirely denies the existence of
muscular dilating fibres in the iris.

" The dilating muscle has never been found, only inferred, from a supposed
physiological necessity. . . . The only fibres that can be isolated from the
circumference of the iris are branching fibrillae, destitute of nuclei, or covered
with nuclei evidently belonging to epithelium, — while the fibres of the sphincter
are easily separable, ribbon- shaped, and nucleated." . . .*

"The arcades, described by KoelHker, are only blood-vessels,
as may be perfectly demonstrated by preparations of injected
specimens."^ "The radiating fibres that immediately surround

' Zeitschrift fur Rationelle Medicin. 1866. Bd. 28, p. 180.

^ Ibid., p. 184. Through the kindness of Dr. Knapp, I have been able
to myself observe these vessels of the iris, with walls whose diameter is at
least half that of their cavity.

220 Mary Putnam Jacob!

the sphincter, and which even Koelliker could not trace to the
circumference, are merely dependencies of the sphincter: those
beyond are elastic tissue.'"

In a word, there is only one kind of contraction of the muscu-
lar fibre of the iris, that which contracts the pupil, in obedience to
a stimulus derived from the retina or brain, and conveyed by the
cerebral nerve, or motor oculi. ^ Dilatation of the pupil is never
active, but, according to its degree, depends on one of three
different causes, ist, simple relaxation of muscular tonicity, or
from absence of stimulus. 2d, contraction of the blood-vessels,
from irritation of the sympathetic. 3d, paralysis of the motor
oculi ; with complete abolition of muscular tonus, and substitution
of the retractility of the elastic fibres. From these consider-
ations we may more clearly understand the mechanism of the
action of atropine on the pupil.

Harley performed the following experiments to ascertain if
atropine affected the sympathetic: — ^

In the first case the sympathetic was cut, and after the pupil
had contracted, atropine was instilled into the eye. Thereupon
the pupil dilated, but only partially, not so much as when the
sympathetic remained intact. In the second case the dilatation
of the pupil was first effected by atropine, and then the nerve was
cut.

The dilatation remained unchanged.

This shows that the influence of atropine upon the sjmi-
pathetic in the phenomenon, though real, is subordinate.

Again, Kuyper'' found that when the pupil had been moder-
ately dilated by atropine, excitation of the superior sympathetic
ganglion increased the dilatation.

This implies that the atropine acts upon another element
in the iris than the sympathetic. The three experiments to-
gether show clearly indeed that the atropine acts by paralyzing
the motor oculi nerve. For the iris, while under its influence,
cannot contract, even though submitted to the reflex irritation
caused by section of the sympathetic. The contracting force is

' Archiv. von Pfliiger. 1 870, p. 287.

' The extremest contraction, as after opium poisoning, is connected
with passive turgescence of the blood-vessels of the iris from paralysis.
^ Edin. Med. and Surg. Journal, 1857.
1 Quoted by B^clard, Traile de Physiol., 1866.

On Atropine 221

annihilated, and this force lies exclusively in the motor oculi
On the other hand, when the sympathetic has been previously
divided, the dilatation caused by atropine is less, for two reasons:
1st. The motor oculi nerve is in a state of reflex irritation, and
consequently more resistant to paralyzing influences. 2d. The
vessels of the iris are dilated, and its tissue turgescent.

Finally, in Kuyper's experiment, the fact that irritation of the
sympathetic increased the dilatation already determined by
atropine, shows that the operation and the poison have acted
upon two different elements, so that their effects can be
superposed.

It is only at the beginning of atropinism, however, that the
mydriasis is moderate, and hence resembles that which occurs
after paralysis or section of the motor oculi. As is well known, the
dilatation continually increases until, in extreme cases, the iris
is reduced to a mere rim. This excessive dilatation cannot be
ascribed to the constriction of the blood-vessels under the influ-
ence of atropine, for although that must necessarily take place,
in the iris as elsewhere, it is only partial, — is an initial pheno-
menon, and its effects would be confounded with those of com-
mencing paralysis of the motor oculi. It can only be due to such
complete abolition of muscular tonus as must result from the
paralysis of the muscular nerve of the iris, the motor oculi. The
retractility of the elastic fibres then comes into play, and reduces
the size of the iris to its minimum.'

The action of atropine in relation to the two nervous systems
present in the iris, cerebral, and sympathetic or spinal, is thus
quite analogous to its action in the heart. It completely para-
lyzes the cerebral nerve, and moderately stimulates the
sympathetic.

Another analogy is revealed by the researches of Keuchel on
the submaxillary gland. It is known that irritation of the chorda
tympani, which, as branch of the facial, represents the cerebral
influence on the gland, increases its secretion; whereas, irritation
of the sympathetic, by determining a contraction of the blood-

' A familiar example of the effect of the retractility of elastic fibre upon
inert muscular fibre may be strikingly seen in the retraction of the uterus
of primiparae after an artificial labor, with complete absence of uterine con-
tractions, yet followed by no hemorrhage; but, on the contrary, the formation
of the "globe rassurant."

222 Mary Putnam Jacobi

vessels, diminishes the secretion.' After injection of atropine,
irritation of the chorda tympani was without effect, and a canula
inserted into the duct remained dry and empty. The condition
was the same as if the chorda tympani had been paralyzed, or the
sympathetic irritated, and there is reason to believe that both
effects had been produced.

In the iris, heart and submaxillary gland, therefore, the
action of atropine is uniform — it paralyzes the peripheric ex-
tremity of the cerebral nerves, and, by stimulating the sympathe-
tic, determines contraction of blood-vessels and acceleration of
the local circulation; hence a double and analogous mechanism
by which it dilates the iris, accelerates the heart's action, and
diminishes the secretion in the submaxillary gland. ^

Therapeutical Applications.

Besides those already well known, upon which we have
insisted careful study of the physiological action of atropine is
continually leading to new applications in therapeutics. I have
spoken to you of the suggestion made by Harley, in regard to the
use of atropine as a diuretic, and as especially adapted for the
treatment of albuminuria. I have had no opportunity to test this
suggestion, and do not know whether it has been tried by other
physicians than Harley. Upon another theoretical deduction
I will however insist, as I have begun to collect some practical
evidence in its favor. The dilatation of the cerebral blood-vessels
that occurs as a secondary effect of atropine, ^ suggests the utility
of this substance in functional cerebral anaemia. One case in
which I tried atropine was that of a woman, who, three weeks

' And which is succeeded, during the rigor mortis, by a moderate con-
traction of the pupil.

2 Keuchel's experiments on the splanchnic nerves above quoted, would
seem to show an exception to the general action of atropine on the sympa-
thetic. I do not know whether they have been confirmed; I have not yet had
an opportunity of verifying them myself.

i On sacrificing a rabbit forty-eight hours after administration of large,
but not toxic doses of atropine, the pia-mater of the brain and cord were
found engorged with blood, and the arteries of the cord dilated. The initial
constriction of the blood-vessels in the nerve-centers, upon which, we believe,
M. Brown-Sequard bases the employment of belladonna in epilepsy, is not in
contradiction with this equally indubitable fact.

On Atropine 223

after confinement, and being then in a debilitated condition, fell
down a flight of stairs. She remained insensible for two hours,
and for two days was unable to walk, although she had received
no external injury but a bruise on the shoulder. On the fifth
day she was still so giddy that she would fall unless she supported
herself as she walked, and suffered from continual nausea, general
muscular weakness, and occasional blurring and blackening of
vision — all persistent effects of the cerebral concussion. I
ordered i-64th of a grain of atropine in solution, three times a
day. The patient felt a sensible improvement in strength after
each dose, as soon as its physiological effects, flushing of the face,
increased dizziness, and a certain mental apprehensiveness, had
passed away. On the following day, the vertigo and staggering
had quite gone. In the second case, the diagnosis was more
obscure. The patient presented herself at the Dispensary for
Nervous Diseases, complaining of vertigo, general muscular
debility, and especially paresis of the right arm, without any trem-
bling. There was a faint blowing murmur at the apex of the
heart. ^ Atropine was given, as an experiment, to try the effect
upon the vertigo, i-64th of a grain, at first three times, after-
wards twice a day. The physiological effects, as in the first case,
were extremely well marked — the flushing of the face intense,
and lasted an hour. Under this treatment the vertigo entirely
disappeared, and the patient gained in strength. The treatment
was afterwards complicated with nutritive tonics and electricity.
In a third case of cerebral and general anaemia, without any sign
of local cerebral lesion, but with vertigo and floating specks
before the eyes, the vertigo quite disappeared under the exclusive
use of belladonna extract. The other anaemic symptoms were
only relieved by blood tonics.

Finally, there remains for us to say a few words on the so-
called antagonism existing between belladonna and opium, in
cases of poisoning. Let us notice, in the first place, that the real
antagonism conceivable is not that between opium and bella-
donna, but between some of the effects produced by the one in the
living organism, and those determined by the other. Now, there

' About six months afterwards this patient developed marked symptoms
of paralysis agitans.

224 Mary Putnam Jacobi

are no two substances whose entire series of physiological effects
are directly opposed to each other. There are no true antidotes
to poisons but such agents as effect a chemical alteration of the
toxic substance, and opium and belladonna have no such mutual
reaction. Moreover, it is certain that the physiological effects of
the two drugs are not in all points contrasted. Mitchell,*
Eulenberg, ^ and Harley^ have shown, both in experiments upon
animals and in observations upon man, that opium and bella-
donna, taken in succession, caused greater acceleration of the
pulse than the belladonna alone; also that when sleep has been
induced by a therapeutic dose of morphine, atropine will not
disturb, but rather render it more profound. (Harley.) The
anaesthesia, diminution of secretions, dysuria, produced by one of
these substances, are determined by the other also, and cannot
therefore be antagonized. But, on the other hand, the pupils
contracted by morphine were seen to widen by atropine, or the
reverse, and the respiration, slackened by morphine, to be slightly
accelerated by atropine. (Erlenmeyer.) Again, though mor-
phine prove unable to slacken a pulse accelerated by atropine, the
fact that atropine accelerates a pulse that has been slackened
by morphine is of the highest importance in toxicology. This
may be seen even in the rabbit, although this animal is much more
susceptible to morphine than to atropine. In a rabbit to whom I
had given hypodermically three grains of morphine in the course
of an hour, the pulse was 148, respiration twenty-four, pupils
moderately contracted, animal in partial stupor, but not insensi-
ble. Three-quarters grain of atropine were injected, and in ten
minutes the pulse had risen to 240, the respiration to thirty-two,
though the pupils were not yet dilated. After injection of a grain
and a half more, the ears became very hot, with marked dilatation
of the arteries. This subsided again after the injection of one-
half grain of morphine. On further injection, in divided doses of
five grains of morphine, the pulse became very weak, but num-
bered about 200. Injections of five grs. atropine then restored
dilatation of auricular arteries, and caused full dilatation of the
pupils, one and three-quarter hours from the time of its first
administration. The animal recovered completely. The effects
upon the rabbit's ears were particularly noteworthy in this case.

' Am. Journal Med. Scienca, 1865.

* Bulletin de Therap., 1867. J Old Vegetable Narcotics.

On Atropine 225

It corresponds to that observed on the ears of guinea-pigs by
Wegner,' and to the well-known experiments of Wharton Jones
on the frog's foot with solution of atropine and Battley's solution
of opium. The attempt to prove or disprove an "antagonism"
between opiimi and belladonna frequently confuses the percep-
tion of the real questions, viz.: What physiological effects of
belladonna are theoretically useful in the morbid state induced
by opium? and further, to what extent do recorded cases of
poisoning show that these effects have been produced? How
have others been modified? Finally, what explanation can be
given of the toleration shown by many patients for one poison,
while they are already under the influence of the other?

This statement of the case is so simple as to almost seem
superfluous, were it not evidently so often overlooked. In the
experiments of Camus, so often quoted, full toxic doses of mor-
phine and atropine were given almost simultaneously, and before
the effects of morphine had had time to become manifest ; in other
words, before the conditions of resistance to the one poison had
been developed by the other. It was to be expected, therefore,
that the animal should feel the full force of both, and succimib.

For the morphine and atropine, even when acting upon the
same organ, and in an opposite manner, affect different parts of
its apparatus. Thus, atropine accelerates the pulse by paralyz-
ing the peripheric extremity of the pneumogastric; morphine
slackens the pulse by increasing cerebral pressure and the tonus of
the central end of the pneumogastric. It is therefore easy to
understand why atropine should accelerate the pulse in spite of
morphine, while morphine should be unable to reduce an atropine
acceleration. When the cardiac end of the pneumogastric is
paralyzed, it avails little that the tonicity of the central end be
increased. And when this has been increased by the opiimi con-
gestion of the encephalon, the effect on the pulse is nullified so
soon as the connection between the heart and brain is severed by
paralysis of the pneumogastric. Again, the contraction of the
pupil, which occurs after irritation of nearly all the organs of the
encephalon, is also determined by the cerebral congestion of
opium. While, to produce dilatation, the atropine acts on the
periphery, on the iris itself, paralyzing the motor oculi nerve, and
so cutting it off from the brain, and moreover contracting its

' Quoted by Stellwag. Der. Intraoc. Druck. P. 6i. Wien, 1868.

226 Mary Putnam Jacobi

blood-vessels by stimulus of the sympathetic. It is evident that
both these effects on the iris might be produced, although no
change had taken place in the condition of the brain, and hence
dilatation of the pupil may occur after administration of atropine
in opium poisoning, yet the patient remain narcotized, and finally
succumb. Thus, in Blake's case,^ the child, who had swallowed
a teaspoonful of laudanum during convalescence from pneumonia,
was treated with eighteen drops of fluid extract of belladonna
in divided doses. The pupils began to dilate after the second
hour, but other symptoms were aggravated, and the patient died
in thirteen hours. Here the effect of the opium was much intensi-
fied by the pulmonary disease, and the dose of belladonna was
small. In one of Norris' cases at the Pennsylvania Hospital, a
man of 55 years, who had taken an ounce of laudanum, was
treated nine hours afterwards with eight and a half grains of ext.
bellad. in divided doses during three hours. At the end of this
time the pupils dilated, but the general condition remained the
same, the pulse almost insensible, and the patient died three hours
later.

Again, there are cases where the dilatation of the pupils
did not occur until after enormous doses of atropine have been
taken, had manifested their influence in other ways, especially
by the acceleration of the pulse, and been followed by a commence-
ment of convalescence. Here the paralytic turgescence of the
blood-vessels of the iris persisted after other symptoms. Thus,
in one of Blondeau's cases, ^ a teaspoonful of laudanum had been
swallowed, and occasioned drowsiness, coldness of extremities,
contracted pupils, but no coma. A fluid drachm of tincture of
belladonna was given in divided doses, and the pulse and temper-
ature rose under its influence, but the pupils remained very con-
tracted until some time after convalescence had evidently set in.

In Duncan's case,^ two ounces of laudanum had been taken,
and the patient was in a profound coma when the belladonna
was given. This persisted after administration of an ounce
of tinct. belladonna in divided doses, and the pupils continued to
contract more and more. Then fifteen grains of extract bellad.
were given by the rectum, and two hours afterwards the pulse
rose, and the respiration became freer. Then two grains more

' Archives Gen., 1864. Quoted from Pacific Journal.

^ Ibid., 1865. i Archives Gen., 1864. Am. Med. Journ., 1862.

On Atropine 227

of the extract were given, and thereupon symptoms of bella-
donna intoxication occurred, with, for the first time, dilatation of
the pupils. Thus the turning-point in the narcotism, as mani-
fested by the effect on the pulse and respiration, was reached
before the pupils were moved, but the return of consciousness was
delayed until the moment of their dilatation.

In the remarkable case related by Constantin Paul,^ where
the injection of an ounce of laudanum had thrown the patient
into a state of intense excitement instead of coma, but accom-
panied by great contraction of the pupil, a large part of the laud-
anum had been rejected by vomiting before any belladonna was
given, and the recovery would probably have taken place with-
out any medication. But the immediate effects of the bella-
donna upon the symptoms were none the less striking. Twelve
drops of tinct. bellad. were given every hour, and in ten minutes
after each dose there was marked amelioration of the vertigo
and violent nausea, though the pupils remained contracted.
The opium symptoms returned in from one-half to three-quarters
of an hour, to disappear again with a fresh dose of belladonna.

By narrowing the interval between the doses, the convales-
cence was definitely established; but not until the patient had
taken over f . 5 ij of the tincture did pallor of the face and dryness
of the mouth appear, while the pupils only dilated after ingestion
of nearly f 5 iv. The effect of opium upon the dilatation of the
pupils, in cases of belladonna poisoning, is more difficult to
appreciate because it is omitted from many of the histories. In
Lee's, ^ however, where a child of 6 years old, poisoned with bella-
donna, was treated with I20 drops of laudanum, it is said that the
purple flush began to fade from the face "as the pupils con-
tracted." In a case recorded in the Dublin Medical Press for
1864, the pupils, dilated and motionless after | grain of atropine,
began to contract under the administration of opium that had
been preceded by an emetic ; at the same time the eruption began
to fade. After 4 grains of opium had been taken the pupils were
normal, and the patient (who was only 2| years old) fell quietly
asleep.

But on the other hand, in a case quoted in the Union Medicale,
1863, where from IQ-15 drops of laudanum were given to a child
26 months old, poisoned by an unknown quantity of belladonna,

^Bulletin de Therapeutique, 1867. ' Am. Journ. Med. Set., 1862.

228 Mary Putnam Jacobi

the pupils did not contract until some time after the patient had
fallen asleep, and convulsive movements had ceased. The age
of the patient in this case renders this fact all the more remark-
able.

Hence observation of facts justifies the expectation of theory,
that in cases of poisoning by one of the two substances, opium or
belladonna, the therapeutic influence of the other cannot be tested
by the state of the pupils, although it is in their movements that
the physiological opposition of opium and belladonna is most
manifest. The pulse affords a much better test. In all cases of
laudanum poisoning with a slow pulse that have recovered
under the administration of belladonna, the pulse has risen in
frequency and strength, and we have already pointed out several
cases where this rise marked the entrance upon convalescence,
and preceded, by a considerable interval, the dilatation of the
pupil. In an observation in the Bulletin de Therapeutique, 1865,
the patient had taken 5 drachms of laudanum, and the bella-
donna was not given until 24 hours afterwards. At this time the
effects of the poison were already attenuated, but there remained
frequent vomiting, the pupils were contracted and the pulse 52.
After hypodermic injection of 10 drops of a solution of atropine at
I per cent., the vomiting instantly ceased, and the pulse rose to 68.

In another case in the Lancet, 1869, the patient was comatose,
with stertorous breathing. The pulse was not counted until
after the administration of | grain of atropine, but it was then
found at 160, and at the same instant the pupils dilated widely.

In one of Blondeau's cases, ' 5 ijss of laudanum had thrown the
patient into stupor, but not coma, and the extremities were cold,
the pulse small, slow, and intermitting. After the administration
of f. 5 j of tinct. belladonna, in doses of 10 and 5 drops the pulse
rose, the extremities became warm, and convalescence progressed
from this moment.^

In Anderson's case, Edin. Monthly, 1854, profound coma had
set in, after ingestion of 9 grains of morphine, taken for delirium

^ Gaz. Hebd., 1865. This case already mentioned, in speaking of the
dilatation of the pupil.

^ This case is rejected by Harley, because the dose of laudanum was
not excessive, and patient might have recovered spontaneously. Never-
theless it does show perfectly the mode of action of belladonna upon opiate
symptoms, when these are not too intense to be modified.

On Atropine 229

tremens during a period of 36 hours. The pulse was slow and
very feeble. 8 drachms of tincture of belladonna were given in
divided doses, f . 5 j every half hour, and then the pulse rose, and
became strong. At the same time the coma was quite dissipated.
In this case the pupils dilated after the 3d dose, before any really
favorable symptom was manifest, but the pulse, respiration, and
consciousness were only affected at the ninth hour.

In Blondeau's second case {Archives de Medecine, 1865) 100
drops of tinct. belladonna were given in the course of an hour and
a half, the patient remaining insensible, and the pupils contracted
and motionless. After the last ten drops the pulse increased in
force and frequency, (the pupils began to dilate at the same time) .
The recovery was assisted by frictions ( ?) of the thorax.

In McGee's case (Am. J. Med. Sc, 1872) the coma, deter-
mined by 30 grains of opium, was combated by subcutaneous
injections of one-fourth of a grain of sulph. atropia, in divided
doses. The pulse rose to 140, and at the same time the pupils
dilated and vomiting occurred, which emetics had previously
failed to produce. There was afterwards some return of the
opium sjTuptoms, somnolence and contracted pupils, but these
disappeared spontaneously, so that the recovery really dated
from the rise of the pulse.

There is only one case on record where the rise of the pulse
failed to initiate recovery. This is the remarkable case of Norris,
at the Pennsylvania Hospital, where 75 grains of morphine had
been swallowed, and marked somnolence had not occurred until
four hours afterwards. Before this time the patient was treated
with tannic acid, an emetic of sulph. zinc and ipecacuanha, a
strong decoction of coffee, and 20 grains of extract of belladonna.
As the coma advanced, 20 grains more of extract belladonna were
given in two doses, the pupils dilated, the pulse rose from 80 to
120, but the somnolence persisted. The patient ultimately
recovered under the free use of stimulants. This case much
resembles that of Camus's rabbits, for the doses of morphine
and belladonna were enormous, and administered nearly simul-
taneously, the first 20 grains of the extract having been given
before the effects of the morphine were well developed. As in
the experiments, therefore, the effects of the two poisons, instead
of neutralizing each other, accumulated, and a belladonna coma
succeeded to that induced by morphine.

230 Mary Putnam Jacobi

In Norris's other case, already quoted, with a fatal issue,
auscultation of the heart showed 120 pulsations, but these were
so feeble that the pulse at the wrist was almost imperceptible.
The atropine failed, therefore, to act as a cardiac stimulant.

In opium poisoning the great danger lies in the congestion of
the brain. The contraction of the pupils, the coma, the slowness
of pulse and respiration are of importance, as symptoms of this
congestion, and the latter more especially, as initiating the
mechanism of death. Any antagonist to opiiun that does not
act as a chemical antidote in the stomach, must act by dissipating
the cerebral congestion. Hence it is not easy to understand
why Harley pronounces atropine useless because "it does not
influence the respiration, where the action of opium is the most
dangerous." The surest way to restore the respiration is to dissi-
pate the cerebral congestion. And this may be done, when the
paralysis is not too complete, by all agents that quicken the
heart's action, and more especially accelerate the circulation
in the brain. Now Harley himself admits that atropine ' ' is one
of the most powerful cardiac stimulants we possess," — he points
out the immediate relief to the nausea occasioned by therapeuti-
cal doses of morphine, from its depressant action on the vagus,
that is afforded by small doses of atropine, which neutralize this
action. It is not therefore true that the cerebral effects of mor-
phine and atropine are not opposed to each other, and Harley's
experiments, showing that the sleep induced by morphine is not
disturbed, but rendered more profound by atropine, does not dis-
prove their antagonism.

In the cases on record, the belladonna has been used when the
patient was in one of two conditions: 1st, a state of restlessness
and intense nausea; 2d, somnolence or complete coma. In the
first case, the relief has always been immediate and striking.
Thus in the first case of Behier,^ the patient had been partially
relieved by abundant spontaneous vomiting, but remained
alternating between somnolence and extremely painful nausea
and giddiness. One-fifth of a grain of ext. bellad. was given,
and immediately these symptoms disappeared. In the case
already referred to, recorded in the Bulletin de Therap., 1865,
the effects of the laudanimi, ingested about eighteen hours pre-
viously, were passing away, but the pulse was at 56, and there

» Archives de Medicine, 1864.

On Atropine 231

was frequent vomiting instantly checked by tlu' injeHtion of a
very minute quantity of atropine. [Sec above.)

The same efTect is seen in the case of Constantin Paul's, al-
ready quoted, where violent nausea and agitation constituted the
main symptoms of the o])ium jjoisoninj;, and were strikinj-jy
relieved by belladonna. As has been said, a marked amelioration
occurred ten minutes after each dose of twelve drops of the
tincture, — and this amelioration was ])('rmanent so soon as the
interval between the doses was shortened from one hour to three-
quarters, which was done after the sixth dose. It is not there-
fore correct to say, as Ilarley does in his comments on this case,
that although the belladonna was given from the second hour
after the poisoning, no decided effect was produced till the fifteenth
hour. It was remarkable in this case, where the opium had
produced agitation and not somnolence, the first phenomenon of
definite recovery was sleep.

In the second class of cases, where the patient was comatose
at the time of commencing the belladonna treatmci)!,, the effect
of this latter is precisely measured by its effecl, on I he pulse.
If the pulse rises, the coma b(;gins to be dissipated, and if the
coma returns, the pulse has fallen again. That the effects of
atropine, like those of other stimulants, should sometimes be only
temporary, and unable to overcome the opium conge;;tion, proves
no more against the usefulness of atropine than against that of
coffee or brandy. That, when the two poisons have been admin-
istered simultaneously or in rapid succession, the more en(;rgetic
effect of atropine on the pulse may be manifested without any
corresponding modification of the cerebral symptoms merely,
show that until the conditions f^f resistance have bec*n developcrl
by the action of one poison, the system is equally open to the
effects of both; but that, in many casf;s (A opium coma, bella-
donna has quickened the heart's action, and by so doing hel[K;fl
to dissipate the cereVjral congestion; that, in a cert.'u'n number of
cases, this effect has been permanent, and even to be attributed to
the belladonna alone, we think unquestionable.

Most of the recorded cases have been tal/ulated by Ilarley,
and commented upon. It is v/orth while to pa;;:-; briefly in review
both the cases and the comments.

In the first three ca^x;s noticed, that of Norris,' iilake,'

'American Journal, 1862. ' Boilon Med. and Surg. Journal, 1864.

232 Mary Putnam Jacobi

and one from the Pacific Journal, 1862, the administration of
belladonna was unsuccessful. We have already noticed these
cases, and pointed out that in none was the pulse perceptible at
the wrist. '

Concerning the case of Anderson, already quoted, Harley
remarks that the coma persisted from 10 to 14 hours after the use
of belladonna. But we have seen that it was dissipated as soon as
the pulse rose.

In Motherwell's case,"" f. § jss of laudanum had been taken
and twelve hours later the patient was completely comatose.
The belladonna treatment was begun the 14th hour, and the
coma did not begin to pass away before the 17th. But this
was as soon as could be expected, and the amelioration coincided
with dilatation of the pupils. [Nothing is said about the pulse.]

Now when, as in some cases considered above, the coma has
been really aggravated by belladonna, the pupils dilate, without
other sign of amelioration.

In Mussey's case,^ there was coma and a pulse of 50, the fifth
hour after ingestion of f. 3 j- of laudanum, which persisted in spite
of vomiting induced by strong coffee at 3d hour. At 5th hour,
grs. vj of ext. bellad. were taken; at 6th hour, f 5i tinct. bellad.
and at 7th hour, coincidently with dilatation of the pupils, the
pulse and temperature improved. By the 8th hour the skin was
warm, pulse 100, and stupor had disappeared.

Harley overlooks these signs of improvement at the 7th and
8th hours, and insists on the fact that consciousness did not
return till the nth hour, 6 hours after administration of bella-
donna. According to him the coma was prolonged by the bella-
donna. But although the patient remained unconscious after
some of the characteristic effects of belladonna were produced,
the sleep lost its stupor and alarming character in two hours after
the administration of the belladonna.

In Lee's case,'' where a child of two years old was in a pro-
found coma from laudanum, tinct. bellad., given in doses of 15
minims, produced a most decided effect. After the second dose
the temperature of the skin rose ; after the third the pupils became

' See above in regard to the cardiac pulsations.

* Med. Times and Gaz., 1862.

^ ATner. Journ., 1862; also Cincinnati Medical.

* Am. Journ. Med. Sc, 1862.

On Atropine 233

sensible to light, and the child spoke; after the fourth, the pupils
suddenly dilated, the face, neck, and arms became scarlet, and
the child began to laugh and cry in the first stage of atropine
poisoning. Recovery was prompt. Concerning this case Har-
ley sa^'s that the necessary details are omitted, because the
quantity of laudanum was not stated. But it is unnecessary to
know the exact quantity of the poison when the condition of the
patient is accurately stated, — since in different individuals, and
different conditions of absorption, the dose required to produce
any given effect is very variable.

In Mitchell's case (iV. Y. Med. Journal, vol. iv.), ingestion of
grs. V. of sulph. morphine had not produced coma 4I hours after-
wards. The patient still answered questions correctly. It was at
this time that f. 5 vj tinct. belladonna were given, and as in
Norris's case, already discussed, the stupor continued to increase
till the loth hour. During this time f . § v of the tincture were
given in two doses, and ^d gr. atropine in four doses. The first
characteristic effect of belladonna appeared at the loth hour after
the first dose of atropine, when the pupils began to enlarge, and
after the last dose there was a scarlet flush from head to foot, with
dryness of the tongue, and soon the stupor was replaced by busy
delirium.

This case is more interesting pathologically than therapeuti-
cally, for the amount of belladonna taken was relatively more
poisonous than the five grains of morphine: and galvanism was
administered between the sixth and tenth hours. The continual
increase of the coma, during the administration of doses of bella-
donna themselves large enough to produce paralysis and coma,
might be attributed to the cumulative effect of the two poisons,
were it not for the absence of mydriasis. This always occurs in
belladonna coma, and we have seen that it may occur when the
system is saturated with belladonna, even though the narcotism
first determined by opium persists. The pulse was already para-
lyzed and 170, before the atropine was given, so that no char-
acteristic effect on it could be produced. It descended, probably
under the influence of galvanism, to 150 and 140, As the
atropine only dissipates the coma by quickening the pulse, it
could not be expected therefore to have any direct effect upon the
narcotism in this case. This case, and the analogous one of
Norris (poisoning with seventy-five grains of morphine, stupor

234 Mary Putnam Jacobi

not till four hours afterwards) can only be explained by an arrest
of absorption. It is on account of such arrest, from paralysis
of the nervous, muscular, and secretive apparatus of the stomach,
that spontaneous recovery has occurred after enormous doses of
opium. Camus has collected a few such cases in his thesis.'
The belladonna is absorbed as gradually as the opium had been,
and being eliminated rapidly by the kidneys, does not accumu-
late in sufficient quantity to produce its own paralytic effects.
Hence two facts, observable in Mitchell's case: ist. That the
first visible effects of doses large enough to produce a coma, were
those that belong not to the latter, but to the initial period of
intoxication, namely, a scarlet flush and busy delirium. 2d.
That a large amount of urine was passed before recovery was
complete. It seems probable, and the hypothesis would be
easily tested by direct experiment, that the diuresis determined
by the belladonna helped to eliminate the morphine from the
system. The experiments of Percy show that one-quarter grain
of atropine would apparently neutralize the effects of a toxic dose
of morphine, when plenty of water was allowed to the animal,
and free diuresis occurred; but that death would follow when,
all other circumstances remaining the same, the supply of water
was cut off. Hence a second, though subordinate mode of action
in which atropine may be useful in opium poisoning. In cases
where its influence as a cardiac stimulant cannot be exerted, or is
unavailing, it may still act as a diuretic, and favor the elimination
of morphine from the system. In Lucas' case, ^ where a child of
eleven had swallowed f. 5 jss. of laudanum, and, three hours
afterwards, was almost completely comatose, Harley lays great
stress on the fact that in the treatment electro-magnetism was
employed as well as belladonna. But this was only given in
order to arouse the patient sufficiently to swallow the bella-
donna, and the effect of each application was most transitory.
The treatment was commenced at the eighth hour, with one grain
ext. belladonnas, and this repeated six times in the course of three
hours. After the fourth dose the stertor was less marked, pupils
less contracted, and pulse 104. After the sixth dose the stertor
quite disappeared, the face was highly flushed, the pulse at 136.
The effect of the belladonna in this case seems indubitable.
Here, f. 5 jss. of laudanum, or forty-eight times the full medicinal
' Theses de Paris, 1865. ' Med. Times and Gaz., 1865.

On Atropine 235

dose, produced coma with cold extremities and livid face in three
hours, showing that absorption had fully taken place. Whereas
in Mitchell's observations, just discussed, after grs. v. of mor-
phine or only thirty times medicinal dose, we have been obliged
to infer that the stomach was paralyzed by the excess, and
hence absorption deferred. It is certainly difficult to explain
this variable action, but the fact is incontestable, — for the patient
was still able to respond to questions at four and one-half hours
after the ingestion of morphine. In the absence of experiments
that might easily measure the rate of absorption, hypothesis is
useless, and mere guessing. It cannot be said that laudanum is
always absorbed more quickly than morphine, for some of the
most striking cases of delay in toxic symptoms have been ob-
served after enormous doses of laudanum.

In Duncan's case, ^ Harley again attributes the prolongation
of the coma to the enormous doses of belladonna (f.5 j tincture,
and grs. xvij extract) that were given; f. 5ij of laudaniun had
been swallowed, and in one and one-half hours, patient was already
almost insensible to external impressions, and sunk in a comatose
sleep. After the administration of the f. 5 j of tincture in a single
dose (preceded by emesis), the coma persisted, and the pupils
continued to contract, the skin grew cold and covered with a
viscid sweat, the pulse imperceptible. Since the pupils re-
mained contracted, it is difficult to attribute this coma to the
action of the belladonna. When the pulse is accelerated without
improvement of other symptoms, it may sometimes be questioned
whether the diffusion of the opium is not thereby favored, and its
toxic effects increased. But in this case no effect was produced on
the pulse. Moreover, if f. 5 j of tincture had added to the opium
paralysis, the additional administration of fifteen grains of extract
should have been fatal; yet after this the pulse rose, and the
respiration at the same time became freer. Two grains more
were given, and an hour later the pupils dilated, regained their
sensibility, the patient was roused from the coma, and replied to
questions.

In Adamson's case^ of poisoning by laudanum, f. 5iij tinct.
belladonna given in divided doses between 3f and 9 hours after-
wards. From the 26. to 5th hour there was no improvement, but
at the 7th hour the patient was sufficiently roused to answer

' Am. J own. Med. Sci., 1862. ^ British Medical Journal, 1866.

236 Mary Putnam Jacobi

questions. Harley objects to this case that other means were
used besides the belladonna; but these consisted exclusively of
an emetic of sulph. zinc at about the 2d hour, which induced no
vomiting; and in the removal of a little fluid by the stomach-
pump.

In Cazin's case, quoted in the Edin. Monthly, 1855, f. 5v.
laudanum had been taken in two doses. 4f hours afterwards the
patient could not be roused from stupor and the pupils were
contracted to mere points. Tinct. belladonna f . 5 J and f . 5 i j
were given between 5! and 5f hours, and at 7th hour the pulse was
stronger, the pupils began to dilate, and the stupor to lessen.
The improvement continued steadily to the loth hour, which
marked definite recovery.

Harley again objects that in this case electricity and emetics
were also used, and that their effects complicate those of bella-
donna. But these means were tried about the 4th hour, and an
hour afterwards, when the first dose of belladonna was given, the
patient was profoundly comatose, as above described. But
improvement began about an hour after last dose of belladonna.

To resume the conclusions that may be drawn from the above
analysis of observations and experiments : —

I St. If very large doses of belladonna be given before the
establishment of opium coma, still more, if given simultaneously
with the opium, the paralytic ^effect of both poisons may be
produced. [See experiments of Camus, which I have repeated
with similar results — case of Norris, case of Mitchell.]

2d. When belladonna is given alone, in doses sufficient to
produce coma, the pupils dilate, and the pulse is accelerated,
until after the most advanced stage, when it falls. When, there-
fore, a coma persists in a patient who has taken both opium and
belladonna, if there is dilatation of the pupils and rise of the
pulse, the coma may be attributed to the accumulated effect of
both poisons. But when the pulse and respiration remain slow
and the pupils contracted, there is no proof that the belladonna
has exerted any influence at all, and the coma must be ascribed
exclusively to the effect of opium not yet counteracted by
medication.

3d. It is known that after excessive doses of opium, symp-
toms of poisoning are often delayed longer than when smaller
quantities have been taken, and the delay is attributed to tem-

On Atropine 237

porary paralysis of absorption. This same condition partly
explains the impunity with which patients plunged in opium
coma bear such enormous doses of belladonna. If only small
quantities are absorbed of the mass contained in the stomach,
while elimination is rapidly going on by the kidneys, some time
might elapse before any great amount is circulating at once in the
blood.

4th. The diuresis determined by atropine favors the elimin-
ation of the opium alkaloids, and in some cases recovery seems to
be mainly due to this cause.

5th. The main action is however upon the circulation. The
capillaries, paralyzed and distended by opium, are directly
stimulated to contract by belladonna, and at the same time
the heart is quickened by being released from pressure of the pneu-
mogastric. A double influence is therefore exerted to dissipate
congestions; and as cerebral congestion lessens, the respiration,
so dangerously menaced, becomes freer.

6th. Hence the therapeutic value of belladonna in any given
case must be calculated exclusively from its effect on the pulse
and on the kidneys. The dilatation of the pupils only shows that
the system is under the influence of atropine, not that that in-
fluence is beneficial. Coma may persist, and the patient die,
with dilated pupils. This is the case when animals are poisoned
by toxic doses of opium and belladonna given simultaneously.

7th. In therapeutic doses, the pulse, slackened by morphine,
is always accelerated by atropine, and the reverse is not true.
The effect of atropine on the pulse is relatively more energetic,
for reasons above detailed. But it is certain that in the majority
of toxic cases recorded, the acceleration of the pulse is only pro-
duced with difficulty, and then coincides with an amelioration of
the narcotic symptoms. In the one or two instances where there
was not such amelioration [case of Norris], the pulse, though ac-
celerated, remained very feeble, so that no real stimulation of the
circulation was produced, but only a double paralysis. There are
cases where immense doses of belladonna have been swallowed
at the very moment that absorption was beginning to take place,
after the temporary stupor induced by opium, and before the
establishment of coma had again diminished its activity.

8th. There is nothing either in theory, or in the observation
of facts to necessitate or justify the enormous doses of belladonna

238 Mary Putnam Jacobi

that have been given. It is known that the acceleration of the pulse
and rise of vascular tension are produced by small doses, and the
contrary effect by large. It is more rational to administer
lUxv of the tincture at intervals of a quarter or half an hour,
and this treatment has been followed by more satisfactory results
than the administration of f . 5 j at a dose. It is absurd to calcu-
late the amount of belladonna needed from the amount of opium
that has been swallowed, for the neutralization required is not
chemical, but physiological, and to be adapted to the reactions of
the organism.

9th. The toleration of such enormous doses of an opposite
poison is none the less a remarkable phenomenon in the pathology
of opium poisoning. When taken simultaneously, the effects are
different from those noticed when the belladonna was given some
time after the opium, though before the occurrence of coma.
These effects are of three kinds, ist. No toxic sjrmptoms may be
observed. [Case of Cazin, ' where a liniment containing f . 5 jss.
of laudanum, and f. B ss. tincture of belladonna was swallowed,
without other result than somnolence and dilatation of pupils.]

In this case the dose of belladonna was not excessive, there was
abundant diuresis [the patient had previously had complete
retention of urine], and this easily explains the elimination of
morphine before any narcotism could be produced.

2d. There may be severe symptoms of poisoning, but followed
by spontaneous recovery. [Case of Christison, — three successive
injections containing each 3ij of opium, and 5 ss of belladonna
leaves.] In this case there was profound coma in three hours,
with dilated pupils, showing predominance of the belladonna
poisoning.

3d. Coma may set in, apparently less profound than results
from opium alone, but tending to a much more rapidly fatal issue.
This has only been seen in experiments on animals, for in the three
cases where death has followed the belladonna treatment, the
doses of belladonna were much smaller than in those that re-
covered. (Grs. vj of extract, in Norris's case, f. 5 ij tincture,
in Blake's and only lU xviij in the case of the child related in the
Pacific Journal.)

Even therefore when several hours have elapsed after the
administration of belladonna, without occurrence of any per-

' Traite de Plantes Medicinales.

On Atropine 239

ceptible amelioration, and where the therapeutic efficacy of the
drug might apparently be called in question, the problem of its
tolerance remains to be explained. We have suggested a partial
explanation in the condition of its absorption and elimination;
we do not affirm that none other is possible nor needed. But the
combination of properties possessed by atropine as a diuretic, a
cardiac stimulant, and stimulator of the vaso-motor nerves,
affords a theoretical explanation of its action that at least lies
nearer to facts positively known than the hypothesis of vague
"resistance." When a certain amount of morphine had been
eliminated from the system by the kidneys, the atropine is then
able to exercise its most important action on the circulation, and
thus directly dissipate the cerebral congestion.

It is extremely important to settle this question by examin-
ation of the urine of patients comatose from opium, and to whom
atropine or belladonna has been given. ^

loth. Belladonna is no "antidote" to opium, nor even to the
entire series of pathological phenomena determined by that
poison. Nor is this surprising, since there are no antidotes to
pathological entities which do not indeed exist. But theoreti-
cally and practically it does modify some of the phenomena of
opium poisoning, and may be used to advantage within the limits
of the following rules.

1st. It should not be given as a prophylactic, but only to
combat conditions already existing, either of restlessness, nausea
and vomiting, or of somnolence, stupor or coma.

2d. It should not be given in large doses, but in small ones
[m xv] frequently repeated.

3d. It is safe to continue the administration so long as the
pupils are not dilated nor the pulse accelerated. If dilatation has
taken place, yet the iris remains motionless, — if the pulse has
become rapid and weak, and coma still continues unabated, —
further use of atropine would only increase the mischief.

4th. The use of adjuvants, as emetics, coffee, if necessary,
electricity, is to be recommended as much in the belladonna treat-
ment as in any other. The previson of the physiological effects to
be expected from belladonna enable us generally to analyze its
influence, even when a complex medication has been employed.

' This elimination in substance of atropine with the urine is known to be
the cause of the dysuria that so frequently attends therapeutical doses.

PATHOGENY OF INFANTILE PARALYSIS/

(Paper read before the New York County Medical Society,
December 22, 1873.)

There is probably no other affection than infantile paralysis
which offers so remarkable a contrast between the frequency of
its occurrence and general agreement in regard to the description
of its symptoms, and the extreme rarity of opportunities that
have been offered for its anatomical investigation. Brunniche^
observed seven cases in one year in a general clinic; and in the
same length of time I have myself observed thirteen cases of
paralysis in children, of which nine were true infantile paralysis.
West^ gives a table of thirty-two cases; Hillier,'' of twenty-four.
Duchenne fils^ tabulates observations of seventy cases. The
books of Dr. Knight's hospital, of this city, contain, in the space
of two years, records of one hundred cases of paralysis, of which
nearly two-thirds belong to the special affection that occupies
us. Volkmann,^ who gives no table, says that he has seen
over one hundred cases; and BarwelP makes an analogous
assertion.

Nevertheless, the number of autopsies recorded since Under-
wood first described the disease, in 1789, is not more than twenty-

' Reprinted from The American Journal oj Obstetrics and Diseases of Women
and Children, 1874.

' Journal ftir Kitidefkrankheiten, Bd. 36, 1861.

3 Childien's Diseases, i860.

" Diseases of Children, 1868.

s Archives Gen., 1864.

<> Sammlung klinischer Vorrdge, No. I, 1870.

1 Lancet, 1872.

340

Pathogeny of Infantile Paralysis 241

.seven, if limited to children, or twenty-nine, if we include two
cases of quite analogous disease observed in the adult. Even
these few autopsies are not all known to even recent writers on
the subject. In i860, Heine,' in his second edition, knew of but
three — those by Hutin, Longet, and Fliess. In 1864, Laborde^
asserts that but four autopsies are known to science — the two
made by Rilliet and Barthez, one by Fliess, and one by Duchenne
and Bouvier. To these he added the two that formed the basis
of his ovm monograph. In 1867, Dr. Taylor, of New York,^
observes that nothing satisfactory has been.- discovered in regard
to the pathological anatomy of infantile paralysis. In 1871,
Gerhardt-^ quotes only four cases — those of Hutin, Longet,
Behrend, and Recklinghausen. In 1870, Meigs^ quotes these
four, the two of Laborde, and one by Hammond {Journ. of Psych.
Med., 1 851), and is unacquainted with any others. In 1868,
Radcliffe quotes six cases, and affirms them to be all negative in
result, including the two of Laborde. ^

In 1872, Smith, basing his opinion upon the same cases, says
that nothing satisfactory is known. '^ Finally, as late as 1873,
Adams ^ asserts that only three autopsies have been recorded —
the two by Rilliet and one by Fliess, to which he adds one by
himself, also negative in character. Since Laborde's cases in
1864, I am aware of fourteen that have been published, and of
these only two, one by Hammond and one by Adams, are known
to or at least mentioned by the authors just named. In the real
or supposed absence of sufficient data to form a positive theory,
conjecture has run wild in framing hypotheses. In regard to
them, it is useful to recognize three distinct phases of opinion,
corresponding to successive anatomical discoveries.

In the first period, opened by Underwood, in 1789, the disease
was defined as essential, i.e., as unaccompanied by any structural
lesion whatever. This is the well-known opinion of Rilliet and
Barthez, and is maintained at much later dates by Kennedy,'

» Die Kinderldhmung, i860. Zweite Auflage.

' Paralysie de I'Enfance, 1864.

3 On Infantile Paralysis and resulting deformities.

* Lehrbuch der Kinderktankheiten, 187 1.
s Diseases of Children.

* Reynold's System of Medicine. t Diseases of Children.

* On Club Foot. » Dublin Quarterly, 1850.

242 Mary Putnam Jacobi

West,' Bierbaum,^ Vogel,^ Bouchut,'' Ketli,^ Politzer,^ Elischer,'
Barwell/ Braun,' and Adams,'" the last seven authors having
written at various dates between 1871 and 1873. Barwell rather
emphatically denounces the existing excessive tendency to local-
ize infantile paralysis in the spinal cord, and reaffirms the essent-
ial, functional, peripheric nature of the disease. On the other
hand, Drs. Taylor," Smith, and to a certain extent Meigs
imitate, to-day, the reticence of Marshall Hall,'^ in 1836, who
declared himself, from lack of testimony, unable to form an
opinion. Roth,'^ who gives a careful resume of several autop-
sies, and even Cornil,"' who has himself contributed one of the
best known, continue this reserve.

Brown-Sequard, in 1 860' ^ and 1861,'^ classed the "so-called"
essential paralysis of children, among reflex paralyses, dependent
upon peripheric irritation, and characterized anatomically by
absence of all lesion in the spinal cord. Echeverria, in 1861,'^
re-enunciated this doctrine, the latter part with much more
emphasis than his master had done, and the theory was accepted
with certain avidity by many English writers, as Churchill, Coley,
and others, who seem to have a national preference for any theory
of disease that evades the necessity of post-mortem examinations.
A second modification of the essential doctrine is represented by
Bouchut, who, from the essential paralyses, separates others
called myogenic, on account of muscular lesions which the author
considers primitive.'^

Much before this time, however, attention had been drawn to
the spinal cord as the real seat of the infantile paralysis, and

' Diseases of Children, 1848. Am. ed. of i860.

' Jahrbuch fUr Kinderkrank., 1859.

3 Diseases of Children. Transl. from fourth German edition . Raphael,
1870.

'^ Bull, de Therap., 1872. ^ Jahrbuch fiir Kinderkrank., 1873.

^ Jahrbuch fiir Kinderkrank., i866. ? Quoted by Kdtli.

* Loc. cit. 9 Compendium fur Kinderkrank., 1871, p. 161.

'"Loc. cit. ^^ Infantile Paralysis, 1867.

" Lectures on Nervous Syst., 1836, p. 81.
^^ Paralysis in Infancy, Lond., 1869.
"• Manuel d'Histol. Path., 1873, p. 637. (2e Partie.)
's Central Nervous System. ^^ Lectures on Paraplegia.

^1 Am. Med. Times, 1861, vol. ii, p. 315.
'* Traits des Maladies des Enfanis, 1862.

Pathogeny of Infantile Paralysis 243

of some material lesion which should be its proximate cause.
As I believe has invariably been the case in the study of diseases
of the nervous system this lesion was at first located in its blood-
vessels, and the paralysis attributed to a congestion of the spinal
cord, or to hemorrhage, capillary or otherwise, into its substance.
This opinion was advanced by Heine as a plausible conjecture,
supported however by the assertions of Muller, Sandras,'
Warnatz,^ and Vogt,^ and with the autopsy of Fliess.'' It was
reaffirmed by Eulenburg in 1859,^ although in his treatise on
Nervous Diseases published in 1872, he is much less positive.
He assigns a central origin to the paralysis, but will venture no
conclusions concerning the nature of the lesion. Brunniche* and
Radcliffe,'' on the other hand, do not hesitate to describe this
lesion as congestion, and Adams admits a slight congestion as the
only alternative to the theory of purely functional alteration.

Dr. Jacobi, in his lectures on dentition, partly combated
Heine's theory as too exclusive, nevertheless inclined to admit its
correctness in a large number of cases, and even assumed a
spinal hemorrhage as the lesion which would correspond most
completely to the symptoms, and especially to the mode of in-
vasion of infantile paralysis. Mauthner, in 1844,^ knew no
other cause for sudden paralysis in children than cerebral or
spinal apoplexy.

In the Lancet for 1870, Clifford Albutt emphatically rejects
a "reflex" origin for infantile paralysis, and ascribes the disease,
in some cases at least, to spinal hemorrhage. He relates a case,
not however of infantile paralysis, but of hemorrhage into the
cervical cord, of which the child immediately died. Hayem, ' in
his thesis on Intra-rachidian Hemorrhages, repeats this case,
and observes that, had the hemorrhage occurred in the lumbar
instead of the cervical cord, the child might have survived and
offered an apparently typical case of infantile paralysis.

Finally Salomon, in 1868/° ascribes the paralysis to an

' Schmidt's Jahrbucher, Bd. 80.

' Schmidt's Jahrbucher, Bd. iv., suppl.

3 Die essentielle Ldhmung der Kinder, Bern, 1 858.

* Journal ftir Kinderkrankheiten, Bd. xiii. ^ Archiv. Virch., 1859,

6 Loc. cit. 7 Loc. cit.

^ Die Krankheiten des Cehirns und Riichenmarkes bei Kindern, 1844.

9 These de Concours, 1872. ^'> Journ. Jiir Ktnderkrank,, 1868.

244 Mary Putnam Jacobi

"exsudation process " in the spinal membranes, by which the cord
is more or less compressed.

In a third period, researches have been made upon the nervous
elements of the cord — researches for the first time conducted by
means of the microscope — and which have founded an entirely
new school of doctrines concerning infantile paralysis. Yet in
this school are several different sects. Laborde originally located
the lesion in the anterior columns and anterior roots, and is sup-
ported in this by Cornil, who communicated a case to the Soci^t6
de Biologic in 1863. Gerhardt follows the French pathologists,^
and Meigs ^ admits sclerosis of the anterior columns and roots to
be, at least, a coincidence in cases of long standing. On the other
hand, Charcot, ^ Joffroy, Parrot, Prevost, '' Vulpian, ^ Roger, and
Damaschino, ^ and Lockhart Clarke^ affirm, as the result of new
autopsies published by them, that the essence of infantile paraly-
sis consists in an inflammatory atrophy of the cells in the anterior
horn of gray substance, especially on its outer side. On the
authority of these same autopsies, this view of the disease is
admitted as highly probable by Meyer^ and Volkmann^ in Ger-
many, Hillier'" in London, Hammond" in New York. In Paris,
Duchenne, father" and son, '^ had, in 1861 and 1864, advanced
nearly this theory as a most plausible hypothesis, * •* before ana-
tomical demonstration could be obtained, and ranked infantile
paralysis with the spinal paralysis of adults, and even with its
acute ascending form, and also with glosso-labio-pharyngeal
paralysis. But since the publication of these facts, Dujardin
Beaumetz has placed infantile paralysis among cases of acute
myelitis,'^ and Hallopeau has described infantile paralysis as a
form of myelitis, to be associated closely with progressive muscu-
lar atrophy, as a parenchymatous inflammation of the anterior
gray substance, and thus notably distinguished from the diffused
inflammations that affect the neuroglia and result in sclerosis. ' ^

' Lehrbuch fur Kinder krankheiten, p. 699. ^ Loc. cit.

3 Archives de Phys., 1870 Revue Phot., 1872.

•» Comptes rendus Soc. de Biol., 1866. s Archives de Phys., 1870.

« Gaz. Med. ,1871. ' Med. Chir. Trans. , 1 868.

* Journ. fiir Ki^iderkrank., 1868.

9 On Electricity. Translated by Hammond.

»» Loc. cit. " Loc. cit. " Diseases of Nervous System,

^i Electris. local., 1861. '* Archives Gen., 1864.

'iDe la Myelite Aigue, These de Concours, 1872. '^Archives Gen., 1871.

Pathogeny of Infantile Paralysis 245

"If," he writes, "we have been able to localize in the posterior comua
the organ of locomotor ataxia., in the same manner we have the right to con-
sider the anterior gray substance as the central organ of muscular atrophy-
Wherever this exists alterations of the anterior horns have been found on
competent microscopic examination; and these amyotrophic lesions are to be
attributed to the same cause, whether they appear in the course of a diffused
myelitis, or under the form of progressive muscular atrophy or of infantile
paralysis."

So Charcot, in his Lessons on the Nervous System, classes
together hematomyelie, acute central myelitis, and infantile
paralysis, as peculiar irritative affections of the central gray
substance of the spinal cord, necessarily resulting in muscular
atrophy. In these affections, of which infantile paralysis is the
most perfect type, everything leads to the belief that the primi-
tive lesion is in the nerve cells, as distinguished from the neuroglia
and reticulum of nerve fibres.^ Vulpian announces the same
doctrine in his Cours de VEcole de Medicine. In the Revue Photo-
graphique for the same year is published a lecture by Charcot
upon the group of myopathies of spinal origin, a group almost
exactly corresponding to that framed in 1861 by Duchenne.
Finally, encouraged by this definite declaration of doctrine on the
part of the illustrious master, Petitfils has sustained, in 1873,
an inaugural thesis under the title, acute atrophy of motor cells,
which is described as the primitive lesion universally existing in
the diseases of this group, namely, glosso-labio-pharyngeal para-
lysis, progressive muscular atrophy, general spinal paralysis of
the adult, and infantile paralysis. ^

Nothing can be more complete than the opposition between
this opinion and that formerly given, and which has so widely
prevailed, that every writer on the subject has felt obliged to refer
to the disease as either essential, or at least as the "so-called"
essential paralysis of children.

Since the change of opinion — which, however, is yet very far
from universal, even among competent authorities — is based
on the results of autopsies, it is necessary to examine these results
in detail to ascertain how far they justify such a revolution, or
what objections may be made to them.

' Legons d la Salpetrihre, 1872.

' These de Paris, 1873. Considerations sur I'atrophie aigue des cellules
motrices.

246 Mary Putnam Jacobi

The appearances described are referred either to the paralyzed
muscles, the spinal cord, or both, and may be grouped into three
classes. In the first nothing was found; in the second, atrophy of
muscles, and lesions discovered in the cord, that, however,
offered no peculiarity corresponding to the peculiar symptoms of
infantile paralysis; in the third, finally, lesions were found involv-
ing one or more of the peculiar elements of the cord, and ana-
logous to those discovered in other cases of disease, which
resembled infantile paralysis in loss of voluntary motion, and in
atrophy of the muscles paralyzed.

1st. Negative Autopsies. — There are seven autopsies on re-
cord, whose results are said to be completely negative. Of these,
three — Rilliet's,' and one by Duchenne and Bouvier, may
be immediately set aside, since it is admitted that no microsco-
pic examination was made. We think that to-day it would be
superfluous to observe, as a recent English writer does with con-
siderable naivete, that "the researches of Mr. Lockhart Clarke
have shown that the microscope may he of very great assistance
in unravelling the pathology of the spinal cord." A fourth
negative case is that reported by Mr. Adams, in his Treatise on
Club-foot. He says, that after a very careful examination, he
was unable to detect any morbid condition of the spinal cord, but
does not specify whether the examination was microscopical, nor
how long a time had elapsed since the occurrence of the paralysis.
A fifth case, more important, was published by Bouchut, in the
Union Medicale for 1867, where a microscopial examination, made
by Robin, could discover nothing in the cord. Finally, in a very
recent number of the Jahrbuch fur Kinderkrankheiten for 1873,
Ketli quotes two autopsies made by Elischer upon paralyzed
children who had succumbed to variola. Microscopical examin-
ation of the cord gave completely negative results, but the
muscles offered examples of two kinds of degeneration, the fatty
and the colloid. Ketli considers these the most exhaustive re-
searches that have been made, and as completely justifying
Bouchut's description of myogenic paralysis, characterized by
primitive granular fatty degeneration of muscular fibre. This
view is analogous to that advocated by Friedreich in regard
to progressive muscular atrophy, a disease so frequently associ-
ated with infantile paralysis by authors who assign a central

*Gaz. Med., 1851.

Pathogeny of Infantile Paralysis 247

nervous origin to both. ^ The latter authors are nearly all more
recent than the former.

Among the six negative cases, therefore, while four are im-
portant, only one can be considered completely satisfactory —
that reported by Bouchut.

Of the next seven cases, five are old, among the first on record.
They are repeated in almost every monograph or chapter on
infantile paralysis. The first case is recorded by Longet in a girl
with a club-foot, who died at the age of eight, the muscles, sciatic
nerve, and its anterior roots on the corresponding side, were all
atrophied. In the second case, from Hutin, paraplegia occurred
at 7 ; death at 45 ; and at the autopsy the lower part of the cord
was found atrophied. In the third and fourth cases the paralysis
was evidently secondary to general organic disease of the cord;
in the one case spinal meningitis (Behrend), in the other tubercle
(Recklinghausen). These latter cases can only show that
pressure exercised upon the cord may produce paralysis whenever
the motor organs of the cord have become involved. They, of
course, cannot be involved as most frequent explanation of
ordinary infantile paralysis. The two cases of simple atrophy
correspond to the lesions found after section of nerves.

The fifth autopsy of this class is that so often quoted from
Fleiss, recorded in the Journal fiir Kinderkrankheiten for 1849.
A child, 5 years old, having passed a restless night, was found
in the morning with the left arm paralyzed. No adequate
cause for the paralysis was discoverable, but the examina-
tion showed in the mouth some decayed milk-teeth. A few
days later the child was killed by a kick from a horse, and at the
autopsy was seen a notable dilatation of blood-vessels around the

' Friedreich gives the following table of authors in two classes, of which
the first assigns a muscular, the second a nerval, origin to the disease.

Nerval
Romberg. Lehrbuch fiir Nerven-

krank.
Fromman. Deutsche Klinik, 1857.
Virchow. Handbuch, 1854.
Jaccoud. Chir. Med., 1867.
OUivier. These de Concours, 1869.
Erb. Deutsches Archiv. 1867. Bd. v.
Trousseau. Chir., 1868.
Charcot Arch, de Phys., 1869.
Clarke Med. Trans., 1 866-1 868.
Hayem Arch, de Phys., 1869.

Muscular
Meryon. Med.- Chir. Trans., 1852-

1866.
Wachsmuth. Zeits. f. rat. Med.,

1855-.
Oppenheimer. Ueber prog. fett.

musk, 1855.
Hasse. Krankheilen des Nerven

Syst., 1869.
Meyer. Wiener Wochenschrift, 1855.
Friedberg. Pathol, und Therap.

Mus. kelldhm., 1858.
Roberts Wasting Palsy, 1858.

248 Mary Putnam Jacobi

roots of the left brachial plexus. This vascular turgescence
extended to the shoulder, the neck, and submaxillary region.

The cerebral meninges were congested, as a result of the
blow. No microscopic examination was made of the cord.

Fleiss attributes the congestion to the irritation of the de-
cayed teeth, and the paralysis to the pressure of the dilated
blood-vessels upon the roots of the brachial plexus. The ex-
amination was too incomplete to permit this explanation to be
accepted as decisive; but this case, like those of Longet and
Hutin, offers no contradictions with later autopsies.

The sixth case is reported by Hammond in the first* volume
of the Journal of Psychical Medicine. Paralysis of the left
leg had lasted four years, and at the autopsy was found an en-
cysted clot, in the left anterior column of the lower part of the
dorsal region. The history of the debut of the disease is not
given, nor are we told whether the cord showed any evidence of
myelitis, or to what symptoms the patient succumbed.

It is remarkable that this is the only case of infantile paraly-
sis in which evidences of a circumscribed hemorrhage have been
found in the cord. The case related by Clifford Albutt is the
following: A healthy child of seven months was lifted up
rather roughly by the mother, fell forward heavily in her arms,
and a few minutes later was paralyzed in its four limbs. Death
occurred by paralysis of the respiration, and at the autopsy
were found two hemorrhagic clots in the cervical spinal cord,
the smaller in the left posterior horn, the larger in the right
posterior.

In quoting this case, Hayem refers to another, the seventh in
our series, where, in a person of twenty-four years of age, who
had been paralyzed when two years old, he found an infiltrated
hemorrhage in the lumbar cord. ^

The third class of autopsies of presumed infantile paralysis,
are all recent, and include twelve cases, in all of which some
lesion was found in the spinal cord.

The first autopsy was published by Comil in 1863. A wo-
man of forty-nine had become paraplegic at two years of age,
and could not walk for six years. After that, was enabled to

' Journal of Psychical Medicine, vol. i. , p. 51.

^ A table of these same cases has been published by Dr. E. C. Seguin, in
the N. Y. Medical Record for last January.

Pathogeny of Infantile Paralysis 249

walk, though painfully, by means of the muscles of the thighs,
although those of the leg and foot were atrophied, especially
on the left side. This false restoration of motor power I have
observed many times myself. After death by cancer of the
pleura, the autopsy discovered complete fatty substitution of
the muscles of the left leg, and incomplete on the right ; atrophy
and fatty degeneration of the sciatic nerves, and diminution
in the thickness of the anterior columns of the lumbar cord. A
great number of amyloid corpuscles were strewn through the
anterior columns. The cells of the comua were intact.

The next two are those often quoted, published by Laborde
in 1864, in which the anterior columns of the cord, translucid
to the naked eye, were found by microscopical examination to
be extensively sclerosed. In the mass of conjunctive elements,
the nerve tubes had atrophied, many had completely disap-
peared, many that remained were varicose. This was especially
noticeable in the first case, a child of two years, who at the age
of eight months, after a short fever, was seized with general
paralysis, soon limited to the lower limbs. In the second case
the child had fever and repeated convulsions at a year old, then
became paraplegic. Before death, a year later, atrophy and
consequent deformity had made much progress. In this case
death occurred from pneumonia, and at the autopsy was found
a remarkable vascularization of the spinal pia mater, and of the
superficial part of the anterior column. The nuclei of the capi-
laries were multiplied, and the walls of these vessels surrounded
by exsudation corpuscles, which also were infiltrated in great
numbers among the nerve tubes. The latter were varicose
and broken in many places, in many others had entirely dis-
appeared. In both autopsies the elements of the comua were
noted as perfectly healthy, as were also those of the paralyzed
muscles.

The fourth autopsy is by Prevost in 1866 (Soc. Biol.). The
history of the paralysis could not be obtained, but at 78, the
time of death, the left leg was paralyzed, muscles soft and flaccid,
the foot in talipes calcaneus. After death these muscles were
found to be completely converted into fat. The inter-muscular
nerve-fibres were unaltered. In the nervous centres, besides
a recent purulent cerebro-spinal meningitis, not diagnosed
during life, was found a marked atrophy of the anterior horn

250 Mary Putnam Jacobi

on the left side. The external portion was converted into con-
nective tissue, colored red by carmine, and in whose meshes
hardly a nerve-cell was to be found. The nerve tubes in the
columns or the anterior roots were intact.

The fifth autopsy belongs to Lockhart Clarke, and is published
in the Medico-Chirurgical Transactions for 1868, as a case of
progressive muscular atrophy. The symptoms are those of infan-
tile paralysis ; the lesions similar to those found by the author in
cases of the latter disease, and consist in foci of granular disin-
tegration in the anterior cornua of the cord, and where the nerve-
cells had disappeared.

The sixth case was communicated by Charcot and Joffroy to
the Soc. de Biol, in 1869. Sudden general paralysis occurred
at seven years, accompanied by a transitory loss of speech. A
certain weakness persisted in the four limbs, which amounted to
permanent paralysis in the left arm. Death at 32. At the
autopsy was found, in the entire length of the cord, a marked
alteration of the anterior cornua, with integrity of the anterior
columns. In the cornua the motor cells had extensively disap-
peared, and been replaced by conjunctive tissue. This alteration
was chiefly marked in the cervical region on the left side.

The seventh case is from Vulpian, and is detailed in the
Archives de Physiologic for 1870. Here, as in Prevost's case, was
no history. At 66, age of death, the left leg was atrophied and
paralyzed, and there was a coxo-femoral dislocation, which the
patient affirmed existed from infancy. After death the para-
lyzed muscles were found to be converted into fat, and the
spinal cord, scarcely altered to the naked eye, showed under the
microscope a species of atrophy of the gray substance in lower
lumbar cord, and a species of sclerosis of the right anterior horn.
At this point the section was less colored by chromic acid, more
by carmine; the majority of the nerve-cells in the external
path of the horn had disappeared, and their place was occu-
pied by new connective tissue, and enlarged blood-vessels. Be-
sides, there was very superficial sclerosis of the anterior columns.

The eighth case appeared also in 1870, and is by Parrot and
Joffroy. The autopsy was made on a child of three years, com-
pletely paralyzed in the left lower extremity, incompletely in
the right. The paralyzed muscles contained an abnormal quan-
tity of conjunctive tissue, but were not fatty. The alterations

Pathogeny of Infantile Paralysis 251

of the anterior horns in the lumbar were precisely similar to
those of Vulpian, and their relative extent on the right and left
side corresponded to the degree of paralysis. There was no-
ticed besides, atrophy of the axis cylinders constituting the
nervous reticulum, to be distinguished from that of the neurog-
lia; atrophy and sclerosis of the anterior columns; and altera-
tion of vessels, whose lymphatic sheaths were crowded with fat
granules. The sclerosis coincided in extent with the lesions of
the cornua, but the alterations of the vessels extended much
further up the cord.

In 1 871 appeared the memoir of Roger and Damaschino,
containing the record of three new cases. In the first case, left
hemiplegic paralysis at two years old, rapidly limited to the
left deltoid, which became much atrophied. Death two months
later of hemorrhagic scarlatina, during which an attack of para-
plegia, principally at the right. The deltoidwas found in
simple atrophy; the left anterior cervical roots congested and
atrophied, and in the cord various foci of alterations in left an-
terior cervical, and also in the right lumbar region. The mi-
croscopic lesions resembled those just described; the cells were
atrophied, and nerve tubes in the roots deprived of myeline;
the vessels were dilated, and their walls covered with fatty
granulations, and the anterior columns were sclerosed; this
about equally on the two sides. The atrophy of the roots ex-
tended all along the cord. The foci of alterations were softened
and visible to the naked eye.

In the second case paraplegia occurred at two years, during
a discrete variola. Death six months later of broncho-pneumo-
nia. Examination of muscles showed some degree of fatty sub-
stitution; of the cord, two foci of softening in the anterior part of
the gray substance of lumbar region, one two millimetres in
diameter, another larger. In these foci the tissue was almost
diffluent, the microscopic lesions the same as in the other cases
and these extended to three and a half centimetres above, where
no alteration was visible to the naked eye. The fatty degener-
ation of the blood-vessels was excessive, a reticulum of conjunc-
tive fibres occupied the centre of the focus, from which the
cells had disappeared, and this was surrounded by a true cyst
wall. No distinct hemorrhage complicated this circumscribed
myelitis. The anterior columns were sclerosed. In the third

252 Mary Putnam Jacobi

case, a child of three years died thirteen months after the inva-
sion of paraplegia, with the ordinary symptoms. Foci existed
in the lumbar region similar to those in the preceding case,
and surrounded also by indurated conjunctive tissue. But mi-
croscopic lesions of the anterior cornua and columns extended
all along the cord.

On account of these complex alterations — degeneration of
blood-vessels, formation of exsudation corpuscles, atrophy of
nerve cells and tubes, hyperplasia of conjunctive nuclei, sec-
ondary sclerosis of anterior columns, — the authors admit a my-
elitis starting, not from the motor cells, as Charcot would have
it, but from the interstitial tissue of the cord.

The twelfth observation is due to Lancereaux, and is published
by Petitfils in his Thesis for 1873. Paralysis of the left arm at
two or three years old, resulting in considerable atrophy. Death
at 18. The muscles were found in simple atrophy, the left an-
terior horn was atrophied in the cervical region, from disappear-
ance of external group of motor cells, and substitution of con-
junctive tissue. A certain amount of atrophy existed in the
left half of the lumbar region. There was no antero-lateral
sclerosis.

From comparison of these twelve observations, by far the
most important on record, it results that five lesions have been
found in the cord in cases of unquestioned or presumed infantile
paralysis, ist. Atrophy of the nerve cells occupying the external
portion of the anterior horn, and atrophy of the nervous reticu-
lum formed by their prolongations.' This in nine cases. 2d.
Atrophy of the anterior roots, and sclerosis of the anterior col-
umns, observed alone in the three first cases of this series pub-
lished, and coinciding with cellular atrophy in four of the other
cases, most marked in the three that offered foci of softening.
3d. Proliferation of conjunctive nuclei, occupying the place
of the nerve cells; in the nine cases these were atrophied.
4th. Dilatations of the blood-vessels, and fatty degeneration of
their walls, described, 'in four cases. It is quite possible that
these existed in some of the others, where they are not de-
scribed, because they had not been expected. 5th. Distinct
foci of softening limited to the anterior cornua on the side cor-
responding to the paralysis, and proportioned in extent to the

' See Boll. Archiv fur Psychiatric, 1873.

Pathogeny of Infantile Paralysis 253

degree of paralysis. These only described in the three observa-
tions of Roger and Damaschino, where the autopsy was made
two, six, and twenty-three months after the occurrence of the
paralysis, and when death had been occasioned by febrile dis-
ease. In the two last the focus of softening surrounded by an
indurated border, which had not had time to develop in the
first case.

On the whole, therefore, the number of cases of infantile par-
alysis, in which lesions of the motor sections of the cord have
been found, greatly preponderate over the negative cases. All
recorded cases with microscopical examination, must, however,
be taken into account, and their variations must be explained
by variations: ist, in the form of the disease; 2d, in the length
of time intervening between the paralytic accidents and the
autopsy.

Different cases of infantile paralysis vary: ist, in their mode
of invasion; 2d, in their march; 3d, in the age of the subjects.

In regard to the mode of invasion of paralysis in children, I
have distinguished nine distinct forms, most of them noticed
among the thirteen cases observed by myself, and twenty-four
selected at random from the collection at Dr. Knight's hospital.

In the first, the paralysis is absolutely sudden, occurs in the
day-time, in the midst of health, while the child is under com-
petent observation. These cases, often represented as typical,
are in reality the rarest of all — only twelve out of one hundred
and sixty-three cases. I have not seen one, nor is one recorded
in West's table of thirty-two cases. There is one among Dr.
Knight's cases, four in Hillier's table of twenty-four, and seven
among the seventy cases tabulated by Duchenne fils; giving a
total of twelve in 163 cases. It is well known that the severity
of the paralysis bears no relation to the mode of invasion, or
these cases might be supposed to be the mildest, which is not,
however, true.

In the second form, much more frequent, the paralysis is dis-
covered in the morning, after a perfectly quiet night ; eight cases
out of my thirty-seven were of this class.

These recall the phenomena of spinal congestion, as described
by Brown-Sequard, where the paralysis is aggravated by recum-
bent position, on account of the gravitation of blood to the
spinal meninges, and also by the first assumption of the vertical

254 Mary Putnam Jacobi

position, owing to the descent of cerebro-spinal fluid. The latter
circumstance, however, would have no influence except in par-
alysis of the lower extremities.

In the third form febrile symptoms occur, generally begin-
ning in the evening and lasting all night, or else two to three
days. When the fever is slight, these cases closely resemble the
morning paralysis of the second class. Eleven of Duchenne's
cases were of this form. He says that the older the patient the
greater is the duration and severity of the fever.

In the fourth form the paralysis is preceded by convulsions
instead of fever. This in four of my thirty-seven cases.

In the fifth class the paralysis occurs in the course of another
disease. In one of my cases the paralysis was observed after
the child had been long kept in bed with purulent conjunc-
tivitis; in two others occurred suddenly during an attack of
cholera infantum. In one of Roger's cases, a child, already
paralyzed in the left deltoid, became paraplegic during the he-
morrhagic scarlatina that caused her death, and at the autopsy,
nineteen days later, a focus of softening was found in the
lumbar region of the cord, presenting the same microscopic
lesions as the cervical focus that corresponded to the deltoid
paralysis.

In a seventh class the paralysis is preceded alone by vomit-
ing. I had two cases of this kind, in one of which the vomiting
lasted two weeks and was followed by crossed hemiplegia.
This case might at first be attributed to a cerebral origin, but
eight years later, the muscles were atrophied without retraction,
and failed to contract under faradaic electricity.

In an eighth class some mechanical accident has occurred.
In none of the cases I have examined was the paralysis immedi-
ate, but preceded by accidents that were the more direct conse-
quence of the paralysis. These are easily overlooked, without
special inquiry. Thus in one of my cases, the mother asserted
at first that the child had been paralyzed ever since he fell
down stairs, but afterwards admitted that he was in bed a week,
with high fever, before the paralysis was noticed.

Only two other such cases are on our list: in one, the child
nearly fell from its nurse's arms, was caught violently by the
lower extremities, and became paraplegic about a month later;
in the other, fell from a wagon, and was lame in two days. In

Pathogeny of Infantile Paralysis 255

all statistics mechanical accidents are very much in the minor-
ity, a fact in striking opposition to their frequency in the etiol-
oly of meningeal or medullary hemorrhage.

We separate a ninth class, in which, with the usual debut of
infantile paralysis, symptoms are observed whose absence is
generally conspicuous. This is a more important class than the
others. In one of our cases the child, at the age of two and
a half years, had a febrile attack, during which a physician pre-
scribed morphine, after which she slept uninterruptedly for
twenty-four hours. On awakening, she was found to be com-
pletely paralyzed and anaesthetic in both lower extremities.
For two days she remained insensible to the prick of a pin, and
for eight days suffered from retention of urine. This case re-
sembles lumbar myelitis. In another case, paralysis of the left
leg was preceded for two days by vague indisposition, and ac-
companied by fever, retention of urine, opisthotonus, and general
hyperaesthesia. The absence of any modification of the sensi-
bility, or of the action of the bladder, in the great majority of
cases of infantile paralysis, renders the occasional presence of
such symptoms all the more important. One similar case is
recorded by West, and two by Hillier.

Although theoretically superfluous, it is often practically use-
ful to remember, that in a tenth class of cases, the paralysis is
either congenital, or has been accompanied by marked cerebral
symptoms, or has existed at first under the form of hemiplegia,
together with facial paralysis; and in the two last, if not in all
three cases, is of cerebral origin, and therefore radically differ-
ent from true infantile paralysis.

Among the thirteen cases seen by myself, twelve had been
diagnosed as infantile paralysis by other physicians, and of
these one was congenital and three certainly cerebral. I have
based the diagnosis in the latter cases on the following points.
First, on the form of the paralysis, which I have never seen
hemiplegic, unless the facial nerve had been involved at the
beginning.

Duchenne fils gives only one case of hemiplegia, that is not
described, and two cases of cross hemiplegia, the latter admit-
ted to be excessively rare. Heine apparently makes a class of
nine cases, but in only one did the paralysis involve an upper
and lower extremity. It followed a fever of several days, and

256 Mary Putnam Jacobi

as Heine did not see the case till years afterwards, a facial par-
alysis might easily have been overlooked by the parents.

In two of West's cases the hemiplegia was congenital, in two
it involved the face, in seven the paralysis was limited to the
facial nerve; in five alone was it confined to a leg and arm of
one side. In two of these it came on gradually; in one suc-
ceeded to remittent fever; in one was preceded by heaviness of
the head for several days, and in one the leg was paralyzed
fourteen days after the arm.

Although, therefore, the hemiplegic form cannot be said to
absolutely exclude infantile paralysis, it is so exceptional as
to offer a strong presumption against the existence of that dis-
ease. The second point of diagnosis is the coincidence of cere-
bral symptoms other than the facial paralysis, which certainly
must be considered as such. It is curious how often these
may be detected in quite a small range of cases. Thus: in
one, the hemiplegia appeared after coma during cerebro-spinal
meningitis. In a second, after a violent convulsion, the face
was spasmodically drawn to the opposite side, and the patient,
a child of seven, remained for a month in a state of intense
maniacal excitement. In a third, developed during convales-
cence from scarlet fever, the hemiplegia was preceded by paresis
during two days, and accompanied for a year by complete
aphasia. In the fourth case, where the child, who had presented
transversely at birth, offered a paralysis of the muscles of the
forearm, principally, and by exception, seated in the flexors,
so that the hand was bent back on the wrist, the extreme localiza-
tion of the trouble was a point of much resemblance with infan-
tile paralysis, or, as the arm had prolapsed during labor and been
replaced, the paralysis might also have been attributed to a
peripheric traumatism. But the first hypothesis was contra-
dicted by the presence of an anaesthesia so complete that the
child constantly chewed the ends of her fingers, and the second
was equally opposed by the complete preservation of faradaic
contractility. The reactions to the faradaic current are well
known to constitute an important means of diagnosis between
cerebral paralysis on the one hand, and those of peripheric or
spinal origin on the other. The value of this test has been much
disputed, but is, we believe, to-day generally admitted.
Duchenne, giving greater precision to the ideas of Marshall

Pathogeny of Infantile Paralysis 257

Hall, claims to have discovered this test. Bouchut disputes
the claim to priority, but admits the value of the test. It is
very remarkable, that in infantile paralysis the loss of fara-
daic contractility is as rapid as is loss of power to respond to
electricity after section of a nerve — namely, in thirty-six hours
according to Harwell, in six to eight days according to Duchenne.
Salomon * has especially investigated this matter, and has en-
tirely confirmed the views of Duchenne, except in regard to the
absolutely bad prognosis that is implied by complete loss of con-
tractility. It was necessary for Hammond and Radcliffe to
discover, as a new fact, that the muscles which failed to react
to the faradaic current, would often, though not always, re-
spond to galvanism. In thirty-seven cases that I have ex-
amined, all of whose histories contained other indication of cere-
bral origin, normal faradaic contractility persisted after years
of paralysis and excessive atrophy. The same is true of those
singular cases of congenital paralysis accompanied by rigid
muscular contractions. In all cases on the other hand, where
such cerebral symptoms were absent, the muscles completely
failed to contract, although their helplessness, atrophy, and
flaccidity were not greater than in the first case. Since in mus-
cles atrophied after long standing cerebral paralysis, faradaic
contractility persists, and since this completely disappears in
infantile paralysis long before atrophy has set in, the phenom-
enon is clearly independent of the condition of the muscular
fibre, and must be connected with that of the nerves. It is ob-
served m diffused chronic myelitis, as well as in infantile para-
lysis, and Vulpian concludes that lesions of the cord determine
in nerves alterations in structure similar to those observed in
their peripheric end after section.

It has seemed to me that the possibility of exciting contrac-
tions by a very slow interruption of a strong induced current,
does not always imply return of power to the nerve. In one case,
where, after two days' convulsions, paralysis of the right arm
had occurred, soon limited to the deltoid, where it was persist-
ing two years later, an ordinary induced current gave no con-
tractions whatever, but these were obtained with galvanism;
and also when the secondary induced current was very slow
and jerking, and applied directly to the muscle instead of through
^ Jahrbuch fiir Kinderkrankheiien, 1868.

258 Mary Putnam Jacobi

the nerve. But after months of treatment with this current,
the paralysis remained unimproved.

Another sort of fallacy is due to the derived currents, which
excite contractions in antagonistic muscles, that are often mis-
taken for movements in those through which the current is
passing, and which really are too much paralyzed to respond.
Thus I have often seen the toes move as the common extensor was
faradaized, but it was evident that they moved only in flexion,
precisely as when the current was passed directly through the
flexors themselves.

Paralysis following diphtheria or other febrile blood dis-
eases, as described by Gubler, must also be separated from real
infantile paralysis. Many cases are really due also to different
accidents than the one to which they are attributed. Thus S.
Weir Mitchell describes a case where a child, shortly after a
fall, was found to be lame in the right leg; but it was discovered
at the same time that decided atrophy of the muscles already
existed, and it was shown that the nerves of the lumbar plexus
were compressed by exsudations that had formed during a severe
attack of typhlitis.

In regard to the march of the disease, three principal varie-
ties are to be distinguished: in the first, the paralysis completely
disappears, either spontaneously or after treatment, in from
two days to a few months. Kennedy's famous cases are of this
description. Barwell asserts that the majority of cases that came
under his observation, are curable when treatment is begun
shortly after the debut of the paralysis. A similar assertion is
repeated by Hitzig and Jurgensen' in opposition to the ex-
tremely unfavorable prognosis of Volkmann. For the personal
knowledge of one such case, I am indebted to Dr. Jacobi. A
lady, affected with chronic endometritis, miscarried several
times from fatty degeneration of the placenta. At the first
living birth the placenta was found to be still partly fatty,
and the child was subject for two years to repeated intestinal
hemorrhages. These were attributed to an imperfect structure
of blood-vessels, analogous to that existing in the placenta.
At the age of two years the child was found paraplegic one
morning upon awakening. No anaesthesia. In three to four
days the paralysis was limited to the muscles of the right leg;

' Archivfur Deutsche Klinik, 1873.

Pathogeny of Infantile Paralysis 259

in a week these still responded well to both currents. No elec-
trical treatment was used, but ergot administered, and ice
applied to the spine. Recovery was complete in two months.

In the second class of cases, the paralysis, at first general-
ized, becomes limited to a few muscles, and there persists in-
definitely. In the third class, finally, the muscles begin very
soon to waste, and the atrophy becomes so general and exces-
sive that the limb dangles about like a loosely jointed stick,
the famous "jambe de Polichinelle " of the French writers.
These cases are too well known to require description or even
illustration, but their frequency seems to me to have been exag-
gerated.

Among the twenty-seven autopsies, the muscles were exam-
ined in fifteen; were found simply atrophied in six; replaced
more or less completely by adipose tissue in eight; and in one
offered no appreciable alteration. There is no well-defined
relation between the date of paralysis and the invasion of the
muscles by fat. It is true, one of the cases above quoted of
simple atrophy is Roger's where the examination was made
two months after the date of the paralysis; but on the other
hand, Hammond has examined the muscular fibre from the
living subject in two cases in which the paralysis had lasted
over four years, and found the structure unchanged. Accord-
ing to Charcot, the rapid wasting of muscular fibre within its
sarcolemma, with persistence of the striations, is alone character-
istic,— ^fatty substitution is always accidental.

In regard to the third variation, that is, in the age of the pa-
tient attacked by paralysis, it would seem at first that this is
settled by the very designation, "infantile," "dental"; and in-
deed, to many it is so. All records, however, contain many cases
in which the accidents occurred after two years old, hence beyond
the period of the first dentition. But, as previously observed, at-
tention has been recently drawn to certain cases of paralysis in
the adult where the symptoms completely resemble those of in-
fantile paralysis. In 1861 already, Duchenne described cases of
general spinal paralysis in the adult, which he considered as quite
analogous to infantile paralysis; and in his third edition he re-
lates four cases that differ, indeed, from infantile paralysis in the
presence of rachialgic pains, but resemble it in the rapid inva-
sion, primitive generalization, and subsequent limitation of the

26o Mary Putnam Jacobi

paralysis. In the thesis of Petitfils are recorded three cases,
observed by Charcot, in adults. The paralysis was discovered
in the morning, in one; after twenty-four hours hemiparesis, in
a second; after four days vague indisposition, in a third. In
one, paralysis was paraplegic from the beginning; in one, gen-
eralized at first, afterwards paraplegic; in one, it successfully
invaded the four limbs. In one there was pain ; in one anaesthe-
sia; in one trembling. In all, faradaic contractility disappeared
in the paralyzed limbs, which grew cold, and atrophied rapidly
for a few weeks, then began to improve, and in one case were
completely restored. Meyer relates two cases that have been
quoted as examples of paralysis, but which are evidently pro-
gressive muscular atrophy. But M. Brown-Sequard has related
to me a case, in an adult, which entirely resembled infantile
paralysis, with extreme wasting, which was ultimately cured.
Cuming'' has seen a case of general paralysis, occurring sud-
denly, after exposure to cold, with nearly all the negative symp-
toms peculiar to infantile paralysis, but followed by darting
pains in the lower limbs, some spasmodic contraction of their
muscles, slight atrophy of the upper extremities, and claw hands.
Return of power to walk in three months. I have seen a some-
what similar case at the Mount Sinai Hospital, but of which
the termination is still uncertain. A man, having vomited
constantly for two weeks without presenting any other symp-
toms, was seized with paralysis of the arms upon going to a
pump in the court-yard. The next day the paralysis had ex-
tended to the lower extremities, and was followed by constant
severe pains in the paralyzed limbs. The muscles wasted rap-
idly; nevertheless, in about three months the paralysis had
become limited to the parts of the limbs below the elbow and
knee-joints. A year later, the patient was still in this condition,
the hands clawed, the feet in slight varus equinus; faradaic
contractility abolished in the muscles that remained paralyzed.

Still another case is related with great detail by Bernhardt,
in the last number of the Archiv fiir Psychiatric (1873). In
every essential respect it resembles the above, and is considered
by the author as identical with the so-called infantile paralysis.
A twelfth case is quoted from Lucas Championniere, in Hallo-
peau's memoir on diffused myelitis, already referred to. Eigh-

' Dublin Quarterly, 1869.

Pathogeny of Infantile Paralysis 261

teen months before death, the patient, on recovery from con-
finement, was suddenly affected by general paralysis ultimately
limited to the left lower extremity. She entered the hospital for
an attack of typhoid fever, and it was then noticed that the
muscles of this limb were extremely atrophied, and that faradaic
contractility was abolished in them. The patient succumbed to
the fever, and at the autopsy the muscles were found in fatty
degeneration, and in the lumbar region of the cord, foci of soften-
ing in the two anterior horns. These were analogous to those
observed by Roger, also after febrile diseases, in the muscles
that remained paralyzed.

In the last January number of the Archives de Physiologie,
Gombault relates a case quite analogous to these, but attended
at first by severe rachialgia. Paralysis remained generalized for
two years, but at three and a half years, use of the four limbs
was incompletely recovered. Death occurred through some
complication, and at the autopsy was found a pigmentary de-
generation of the cells in the anterior horns, lesion generalized
all along the cord. The anterior roots were atrophied, the an-
terior columns, and all other parts of the cord healthy. The
paralyzed muscles were sclerosed, and the sarcolemmae generally
empty. This valuable autopsy may justly be classed with those
already related of infantile paralysis.

It appears, therefore, that the age of the patient cannot be
reckoned as an absolutely essential circumstance to the produc-
tion of the most typical characters of the disease. All that can
be affirmed is, that it is much the most frequent between the ages
of six months and two years. On comparing the symptoms of
infantile paralysis with the results furnished by autopsies, we find
that a certain number among both, one and the other, may be in-
voked in favor of one or the other pathogenic theories we have
enumerated. The sudden invasion, and occasionally complete
spontaneous disappearance of the accidents, together with the
negative results of four autopsies, have been supposed to prove,
now the "essential," i.e., functional character of the disease, now
to indicate a transitory congestion of the spinal cord. These two
theories are often grouped together, as if supposed to be very
nearly identical; as when Adams says that infantile paralysis is
either a functional disease, or else depends on some slight spinal
congestion. But in reality the two ideas are completely distinct.

262 Mary Putnam Jacobi

For the hypothesis of spinal congestion, so seriously defended by
Radcliffe, presupposes at all events that the lesion, however tran-
sitory, is central. Whereas the assertion that infantile paralysis
is essential, functional, immediately conveys to many, and is
perhaps meant to conve3^ the idea that only the function of the
motor nerves is abolished, and that an essential paralysis is,
unless reflex, essentially peripheric. Especially in regard to
infantile paralysis has the localization of the affection been
considered a proof that the cause of the disease was to be sought
on the periphery of the nervous system. Now the function
of a nerve is unique and well understood — that of conducting
impressions. So long as these impressions, motor or sensitive,
continue to be generated, the function of the nerve can only
be interrupted by interruption of the road along which the im-
pressions travel; and further, the same cause that suspends the
conveyance of one of impression must, in the great majority
of cases, suspend that of the other, so that a complete motor
paralysis, dependent on an affection of a nerve, is nearly always
accompanied by anaesthesia. It is true that this is by no means
always in proportion to the degree of motor palsy, and a case
related by Mitchell may be paralleled by others, where sudden
and complete paralysis caused by dislocation of the humerus,
was accompanied with scarcely any loss of sensation. ' Still the
rule is the other way, and implies conditions directly opposed
to those of infantile paralysis, where modifications of the sensi-
bility are extremely exceptional.

But further, from the almost mechanical nature of the
function of the nerve, it is difficult to imagine an interruption
to this function dependent on other than mechanical or, at
least, physical conditions, and it is so difficult to demonstrate
an immaterial abolition of function, that indeed it has never
been done. It is as easy to show that wire may become imper-
vious to the passage of electricity, unless it be severed or clogged
by non-conducting substances, as that a nerve whose struc-
ture is intact may nevertheless refuse to conduct impressions.
Hysterical paralyses and anaesthesias prove nothing in regard to
functional alterations of nerves, until it can be shown that
the loss of motility or sensation in hj^steria be really entirely
independent of alterations in the activity of the cells. There

' Injuries of Nerves, p. 102

Pathogeny of Infantile Paralysis 263

are only five cases in which paralysis of a nerve can be posi-
tively traced to causes confined to the nerve, when namely it
has become inflamed, or has been severed, frozen, contused,
or compressed. The experiments of Vulpian and Bastien, '
Tillaux,^ Waller, and Mitchell, have shown that in the last four
cases the alteration of structure is as decided as in the first.
"A nerve trunk," observes Mitchell, "is made up of a multitude
of tubes, the contents of which are so nearly fluid as probably to
be capable of more or less movement to and fro. When to
such a bundle we apply a tight ligature, no matter how soon it
be relaxed, we annihilate at once all power of the nerve to
transmit impressions past the injured zone. After gradual and
equal pressure the nerve is for a time incapacitated, but soon
regains its normal abilities. It seemed to me that the reason
for such loss and such return must be a purely mechanical
disturbance of the tubal contents and a like mechanical restora-
tion of their needed conditions of activity." To test this
hypothesis, Mitchell submitted the sciatic nerve of a rabbit to
pressure of mercury standing in a tube at varying heights. The
conducting power of the nerve persisted until it had been pressed
upon by twenty inches of mercury, then disappeared, but
began to return in about fifteen seconds after removal of the
pressure.

It is paralysis by compression that most nearly resembles the
hypothetical "functional" paralysis, inasmuch as an organic
lesion is imperceptible to the naked eye. Yet it is only the
first stage of another, which can be demonstrated after slight
contusion of nerves. When Mitchell struck a nerve smartly
with a smooth broad whalebone slip, allowing a thin layer
of muscle to intervene, the paralysis which ensued, although
often temporary, was in degree complete. In these instances
there was usually little hemorrhage, but a few fibres were torn,
and a large proportion suffered simply from mechanical disturb-
ance, which gave them for a time a baccated look, and irregu-
larities of outline, due to displacement of their semi-fluid contents.
If such a nerve be examined within a few days, when the
paralysis has disappeared, the nerve tubes present but very
slight traces of mechanical alteration, and a still later inspec-
tion rarely shows greater alteration of the nerve, save in a very

' Gaz. Med., 1855. » Quoted by Mitchell. Loc. cit., p. 92.

264 Mary Putnam Jacobi

few fibres.^ Finally, even section of a nerve acts otherwise
than by merely separating the nerve tubes from the nerve
centres, for it is well known that the structure of the tubes
begins to alter in a few days after such an operation, and that
the myeline segments and finally disappears before the nerve
atrophies. The morbid process therefore is identical with that
in the other cases, and it may be therefore positively asserted
that there is no abolition of the conducting power of a nerve,
without disturbance of its myeline.

The rapidity with which a nerve recovers from paralysis
caused by compression or contusion far exceeds the rapidity of
recovery in infantile paralysis, except in such cases as those of
Kennedy's which are by no means the most common. If, therefore,
a mechanical lesion exist when paralysis disappears in a few
days, much more should it be present, if due to peripheric
interruption of nerve function, when the paralysis has lasted
for months or years. A "peripheric" paralysis is therefore just
the reverse of an "essential" paralysis.

The effects of compression and contusion differ from the
phenomena of infantile paralysis in that they are gradually in-
duced, the paralysis is preceded by paresis, and by modifica-
tions of the sensibility, both absent in the disease under consid-
eration. In infantile paralysis the loss of motility resembles
that due to only one peripheric lesion, namely, section of the
nerve. This is especially true in the absolutely sudden cases.
The abolition of faradaic contractility and the rapidity of muscu-
lar atrophy are also striking points of resemblance. It is evident,
however, that the first effect of section is not upon the nerve in
itself, but only upon the relations between it and its centre,
and the structural alterations of the nerve that follow are not
apparent until from four to six days later. ^ A sudden arrest in
the generation of motor force at the centre would be manifested
in precisely the same way as a sudden interruption in the line
of conveyance of such force, and indeed in no other way; just
as there is but one phenomenon to indicate the cessation of
chemical action in a battery where electricity is evolved, and
interruption of the current from section of the wire by which

' Loc. cit., p. 93.

» Mitchell, loc. cit., p. 75. Lavuran, Thhse de Strasbourg, 1864 (quoted by
Mitchell). Vulpian, Arch, de Phys., 1869.

Pathogeny of Infantile Paralysis 265

it is conducted, namely, absence of action. On the other hand,
section of the nerve and section of the spinal cord at the point
where it is given off, are followed by identical lesions of the
nerve tubes, namely, loss of transparency, segmentation of mye-
line, irregular contour of tube wall, disappearance of tube con-
tents, proliferation of inter-tubular connective tissue, ultimate
atrophy. There is no evidence, therefore, that an alteration in
the functions, i.e., of the conducting power, of nerve fibres ever
exists apart from some material alteration in their structure, and
no suddenly produced material alteration can be even suspected
in the type cases of infantile paralysis.

There remains, as the conceivable seat of the so-called "essen-
tial" paralysis, one of two alternatives — a functional alteration
of the ultimate nervous fibrillas, at the point where they enter into
intimate combination with muscular fibre, or a similar alteration
at the other extremity of the nerve, where the axis-cylinders,
from its spinal root, form the anterior nervous reticulum of the
cord, and continue with the prolongations from the motor cells. ^
The possibility of a localized paralysis of the nerve-muscle
element was first suggested by the now familiar phenomena
of poisoning with woorara. The peripheric action of this drug
was demonstrated by its effect upon nerves isolated from their
centres, and its failure to paralyze others isolated from the vas-
cular system through which the poison was circulating. A
paral^^sis of this nature has, therefore, always been associated
with a morbid alteration of the blood. To such alteration, and
the demonstrable structural lesions of muscular fibre, may be
probably attributed diphtheritic paralyses, and others observed
during convalescence from various fevers, so well described by
Gubler; and many cases of so-called infantile paralysis, devel-
oped in such connections, are undoubtedly of this kind. But
no such blood-poisoning can be suspected in the type cases of
infantile paralysis, nor in its absence can any alteration of the
ultimate nerve fibrillae be supposed. There remain, therefore,
the spinal motor cells as the only possible seat of functional
alteration, which indeed is more conceivable of elements whose
functions are so delicate and complicated. Whether infantile
paralysis be essential or not, it certainly must be central in its
origin. It is the first, or negative class of autopsies, four in

^ Boll. Archiv ftir Psychiatrie, 1873.

266 Mary Putnam Jacobi

number, which seem to support the idea that the central altera-
tional is functional. The only alternative is between an annihila-
tion of function in the motor cells of the cord preceding or in-
dependent of any appreciable alteration of their structure, and
a similar arrest of function, as a consequence of structural
lesion. All truly negative autopsies, of which there are in
reality only four, speak in favor of the first hypothesis. It re-
mains to be seen how far or in what way the results of other
autopsies speak in favor of the second, or how the two classes
of facts can be reconciled.

The theory of spinal congestion has been based, first, upon
the same clinical facts invoked in support of the "essential"
theory; second, upon others — such as the frequent appearance of
the paralysis in the morning, its original generalization followed
by limitation, the absence of rachialgic or of peripheric pains,
the gradual improvement, or even cure; third, finally, partly
upon the purely negative autopsies, partly upon the one recorded
by Fleiss. It is noticeable that this latter was not in reality
an example of congestion of the cord, but of the spinal meninges,
and was accompanied by congestion of the cerebral meninges,
justly ascribed to the accident that had caused the death. As
regards the clinical history of spinal congestion, it differs from
that of infantile paralysis — first, by the absence of important
phenomena, characteristic of infantile paralysis, as the aboli-
tion of faradaic contractility and the rapid muscular atrophy;
second, by the presence of others not seen in the latter
disease, as the invariably paraplegic form of the paralysis, the
various modifications of the sensibility, as tingling, aching,
burning, muscular fatigue; finally, by the frequency of pare-
sis, which never precedes infantile paralysis, whatever the dura-
tion of constitutional symptoms. There are certain cases,
however, whose history does remarkably correspond to that of
spinal congestion. The case I have quoted from Dr. Jacobi is
a type of this kind, and is distinguished by the coincidence of
conditions indicating a congenital imperfection of blood-vessels,
predisposing to hemorrhage; by the preservation of faradaic
contractility, and by the cure of the paralysis under the influ-
ence of agents calculated to diminish the circulation of the
spinal cord.

In ordinary cases of spinal congestion, the peculiar symp-

Pathogeny of Infantile Paralysis 267

toms depend on the generalization of congestion to the entire
thickness of the cord, including its sensitive regions; and the
absence in infantile paralysis is explained, in the theory, by a
hypothetical limitation of congestion to the motor regions. The
possibility of such limitation of vascular turgescence is presup-
posed no less in the theory of hemorrhage than in that of con-
gestion. It is necessary, therefore, as the basis of an exami-
nation of these two theories, to consider: ist, the anatomical
facts relating to the distribution of blood-vessels in the spinal
cord; 2d, the pathological lesions that have been really dis-
covered in cases of spinal congestion or extravasation; 3d, the
clinical history of the symptoms that have been observed in
connection with such lesions.

In the distribution of blood-vessels to the cord, the following
circumstances are noteworthy :

The spinal arteries are derived from the vertebral, but rein-
forced all during their course by anastomoses with the ascend-
ing cervical, intercostal, lumbar, and lateral sacral arteries.
There are two classes of veins — those which bring the blood
from the cord and belong to the real medullary circulation,
and those which are interposed between the dura mater and
the walls of the bony canal, and which form the so-called verte-
bral sinuses or intra-rachidian plexuses. These differ from
the cerebral sinuses by their frequent anastomoses, are but
loosely supported by the dura mater, and surrounded by a
semi-fluid fat. The circulation in these extra-meningeal veins
is in close dependence upon the double rhythm determined by
the movements of circulation and respiration in the thorax,
and liable to be affected, therefore, by lesions of the thoracic or-
gans. These facts show a tolerably rich circulation both in the
cord and its membranes ; but the two last alone can be supposed
to especially favor hemorrhage and that not into the cord, but
in or outside of the membranes, and then not as a primitive
accident, but as a consequence upon well-defined organic disease
elsewhere. There are two anterior spinal arteries, and only one
posterior; and the capillary network of the gray substance is
richest in the anterior cornua. These are the two facts that
might seem to render vascular turgescence or rupture more
probable into the anterior than into the posterior segment of the
cord.

268 Mary Putnam Jacobi

Finally, the anastomoses formed between the spinal arteries
and veins, and those which reinforce them, exist at the level of
the spinal roots. In turgescence of the vascular system, there-
fore, pressure would be especially felt at this point, and might,
if sufficiently intense, be supposed to interrupt nerve currents.

The force of the foregoing considerations is, however, much
weakened by the following :

The arteries and veins furnished to the dura mater from the
vessels contained in the vertebral canal, are separated from the
cord by expansions of the vertebral ligaments. The cord is
thus protected during turgescence of these vessels — at least of
:mch as are of large size. The branches that enter the cord are
of remarkably small size as compared with those of the brain,
and subjected to much more numerous inflections. The pia
mater into which they plunge, and by which they are sheathed,
is much firmer than that of the brain. According to Retzius, '
it consists of two layers, one lining the subarachnoid space, one
closely applied to the cord. The subarachnoid space is large,
and occupied by septa of connective tissue, among which cir-
culates freely the cerebro spinal fluid, constantly tending to
restore equilibrium of pressure upon the cord. The anastomoses
around the nerve roots are so free and extensive that an afflux
of blood towards the cord from without, that should remain
limited to one or two pair of roots, is almost inconceivable. Simi-
larly, the anterior capillary networks of the axis communicate
freely at the periphery with posterior network, and with those
above and below them; so that the gray substance of the cord,
instead of being divided into distinct vascular territories, as is
the case with the brain, contains a sort of uninterrupted vascular
column, at any one point of which the blood is with difficulty
obstructed. Finally, the danger of interference from action of
the heart, is diminished by the nearness of the heart to the cord ;
and the influence of respiration is lessened from the fact, that
while the meningeal veins empty into the superior vena cava
during inspiration, they are free to empty into the inferior cava
during expiration, so that a double provision is made against
their obstruction. This is in contrast with the provision for the
brain, and in accordance with the greater immediate danger to
life from extensive congestion of the spinal cord.

' Schultze's Archiv, 1873.

Pathogeny of Infantile Paralysis 269

It follows, therefore, that the normal anatomy of the cord
tends to render medullary hemorrhage extremely difficult, for
every provision is made against such local obstructions to the
circulation as, by increasing local vascular tension, are known
to be the efficient cause of hemorrhage into the brain. Nor has
yet been demonstrated in the spinal arteries, the lesions, athero-
ma, embolism, thrombosis, which are so common in the cerebral.
Liouville alone, in a single case, was believed to have discovered
miliary aneurisms. ^ But none of these lesions exist in children,
or would be suspected in cases of infantile paralysis.

A general venous congestion of the cord is from the anatomy
conceivable, and from clinical facts demonstrable; but such
localization of the congestion as would be required to explain
the phenomena of infantile paralysis, is as incompatible with
the free vascular communications just described, as are the
sj'-mptoms of spinal congestion and those of the latter disease.
It is true that four of the autopsies besides that of Fleiss, describe
a dilatation of blood-vessels limited to the anterior cornua of the
cord, but this was associated with alterations in the nutrition of
anterior cells. Local variations in cellular activity do, indeed,
determine local variations in the circulation ; indeed the phenom-
ena of capillary circulation are well known to depend mainly upon
the action of cells. In such cases, it is the alteration of the cells
which is the efficient cause of the disease, the congestion is con-
secutive, subordinate, and as an explanation of the paralysis,
already necessitated by the cellular affection, may be set entirely
aside.

These considerations are still further sustained by analysis of
the histories of spinal hemorrhage, — reputed a primitive acci-
dent. Hayem has analyzed lOO cases of hemorrhage into the
cord or its membranes, and affirms that this is the entire number
hitherto recorded in science. Of the cases of meningeal hemor-
rhage all but five were evidently consecutive to some other lesion,
as, rupture of a neighboring vessel, especially with an aneurism,^
extension of a cerebral hemorrhage, traumatism, certain diseases
of the nervous system, as tetanus, epilepsy, chorea, inflamma-

' Quoted by Hayem, These sur les Hemorrhagies Intra-rachidiennes, 1871.

From this thesis much of the foregoing has been taken.
' Laennec, Traite d'AuscuU., t. iii., 4^ edit. p. 443.

270 Mary Putnam Jacobi

tions; ' finally, to certain abdominal diseases, to fevers, altera-
tions of the blood, or poisoning, especially with strychnine.

Of the five cases of meningeal hemorrhage that seemed the
most purely primitive, in the first (Obs. Binard^) the vessels
ruptured under the influence of a violent effort; in the second^
and third'' (Ollivier and Fallot) an encephalo-rachidian conges-
tion preceded the hemorrhage; finally, in two cases, Gintrac-'
and Bigot, ^ the hemorrhage occurred amidst symptoms of long-
standing, indicating a spinal pachymeningitis.

The cases of asserted hemorrhage into the spinal cord are
still more ambiguous.

Two facts are common to all: ist, the clinical symptoms of
hemorrhage are preceded by a traumatism, or by symptoms of
a myelitis; 2d, at the autopsy the hemorrhagic clot is found
imbedded in tissue softened to a much greater extent than could
be explained by its pressure, or presenting at least microscopical
evidence of a central diffused myelitis.

As an illustration of the usual history of such cases, I will
relate the details of one, of which I was recently enabled to
witness the post-mortem examination. The patient, a man of
28 years old, after exposure in a snow-storm, was attacked by a
severe pain in the lower part of the back, that, after lasting two
or three days, was followed by paralysis of the left leg. This,
however, gradually disappeared, so that three months later, the
patient considered himself well, when one day, upon entering an
omnibus, he suddenly lost all power over his lower limbs and fell
to the ground. He was carried home, and although incapable
of standing or walking, was able to move the legs a little when
lying in bed. The paralysis extended to the sphincters, and was
accompanied by complete anaesthesia of the lower extremities.

' Bouchut, Gaz. des Hop., 1863.

Joffroy, Soc. de Biol., 1870.

Thure, Arch. Gen., 1845.

BcUingieri, Gaz. Med., 1834.

Griesinger, Arch, der Heilkunde, 1862.

Fuller, Lancet, 1862.

Calmeil, Traite des Maladies de I'encephale, 1859, t. i., p. 167.

Ollivier d' Angers, t. ii., p. 350.

Bruggenmann, Schmidt's Jahrb., 1836. And others.
' Quoted by Hayem. ^ Loc. cit. ■* Archives Gen., 1830.

s Path. Int., t. vi., p. 721. ^ These de Paris. 1847.

Pathogeny of Infantile Paralysis 271

In an hour or two the pain in the back returned, and became so
extremely severe that, about the second day after the fall, mor-
phine injections were used; a few hours later the pain disap-
peared, but the motor paralysis was so much increased that the
patient could not stir in bed. In the course of three or four
months motor power was sufficiently regained to allow the patient
to creep about a little on crutches ; but he remained generally in
bed, and eschars of the sacrum and of the ischial tuberosities
developed in July, about six months after the fall. He sank
gradually, and died in October of pulmonary oedema, without
the occurrence of any sudden accidents. At the autopsy was
found, in the upper part of the lumbar cord, a hemorrhagic clot
that filled a cavity about an inch long, and occupying the entire
thickness of the cord. Around it for a quarter of an inch the
cord was softened and altered in color.

At the earliest this hemorrhage could not have taken place
before January, and then would have been preceded for three
months by symptoms of myelitis. A case related by Lancereaux
in the Soc. de Biologic for 1861, shows that hemorrhage may
occur in the course of a myelitis without adding any new symp-
toms to those already existing.

In thirty cases of hematomyelie analyzed by Hayem, the
symptoms were analogous to those of myelitis, and in all at the
autopsy the clot was found surrounded by softening too exten-
sive to be the mere effect of the hemorrhage. In the famous
case described by Cruveilhier, although there was a circum-
scribed hemorrhage and a clot that extended from the level of
the fourth to that of the sixth cervical vertebra, blood was also
diffused throughout the entire gray substance of the cord — a
lesion which almost necessarily indicates a central myelitis. ^ So
in one case related by Brown-Sequard ^ small clots were found in
the centre of the cord, between the origin of the second and third
dorsal nerves, and the cord itself was softened and infiltrated
from the third cervical to the last dorsal pair. Brown-Sequard
quotes two other cases, in neither of which the hemorrhage was
circumscribed. In a case by Jaccoud, the hemorrhage had oc-
curred in the lumbar region, but coincided with an enormous
cerebral hemorrhage. In a case communicated by Liouville to

' Anat. Path., iiie, Livraison.

' Lectures on Central Nervous System, p. 87.

272 Mary Putnam Jacobi

the Soc. de Biol. (1872), two attacks of paraplegia occurred sud-
denly at three years' interval, and death two months after the
second attack. Several distinct hemorrhagic foci were found in
the lumbar cord, and the small blood-vessels in the neighborhood
presented varicosities that Liouville considered analogous to the
miliary aneurisms he had previously described in the arterioles
of the brain. In another case, quoted by Hayem from Massot,
a sudden paralysis of both arms had been followed by very rapid
atrophy of their muscles, and also of those of the neck, thorax,
and, to a less extent, of the lower limbs. Faradaic contractility
was entirely lost. Death occurred suddenly, and at the autopsy
a small hemorrhagic clot was found in the central gray sub-
stance and posterior horns of the inferior cervical cord. But
a reddish color extended over the greater part of this gray sub-
stance, although the blood itself was not infiltrated. It is to the
alteration indicated by this color, that must be attributed the
previous paralysis and muscular atrophy, while the hemorrhage,
which must have immediately preceded the death, was secondary
to this.

It sometimes happens that the symptoms of an acute myelitis,
uncomplicated with hemorrhage, exactly resemble the accidents
usually attributed to hemorrhage itself. This is well shown by
a case of Roster's, recorded in Canstatt's Jahrbuch for 1870.
A man, hitherto healthy, found himself one morning, on awaken-
ing from sleep, to be completely paralyzed and anaesthetic in
the lower extremities. No previous symptoms had occurred,
except a little tingling in these same limbs during a few days.
There was no pain, but soon dyspnoea, and then an eschar de-
veloped, which caused death by septicemia in two months. At
the autopsy the lumbar cord was found softened and atrophied,
as were also the anterior roots, but there was no trace of hem-
orrhage. Other similar cases might be quoted. Since, there-
fore, the symptoms ascribed to hemorrhage may be identical
with those due to myelitis, — since in cases where hemorrhage
has really occurred, it has been preceded by symptoms of myeli-
tis,— since, finally, at the autopsy, the hemorrhagic clot is found
embedded in tissues softened and altered in a way to present
all the characters of myelitis, — we are justified, we think, in
admitting with Hayem, Dujardin, Beaumetz, Charcot, Hallo-
peau, and Koster, that a primitive hematomj^elie is among the

Pathogeny of Infantile Paralysis 273

rarest of pathological accidents, and that hemorrhage hardly
ever occurs into the spinal cord, unless its tissues have been
previously altered by inflammation. This corroborates the in-
ferences already drawn from the normal anatomy of the cord,
that hardly any condition of hemorrhage can be found to exist
in the distribution of the blood-vessels themselves. There is,
therefore, the strongest presumptive evidence against the idea,
that such a rare accident is the cause of so common a disease
as infantile paralysis. Nor do the symptoms of such accident,
when occurring, in the least degree resemble those of this dis-
ease. They are hyperaesthesia or anaesthesia, as sudden and com-
plete as the motor paralysis, — exaggerated reflex actions, tetanic
contractions, where the hemorrhage is meningeal — rachialgia
and peripheric pains, paralysis of the sphincters, production of
eschars, march rapidly progressive, and towards a speedily fatal
termination. It is true that, as in the theory of congestion,
these symptoms would depend upon the extension of the lesion
to other than the anterior regions of the spinal cord; and the
theory of hemorrhage in infantile paralysis supposes, as in the
case of congestion, a localization of the morbid process to the
anterior cornua or columns. But for the same reasons as in
this first case, such localization is only conceivable as a capillary
phenomenon dependent on the morbid nutrition of cells, to
which, therefore, it would be quite secondary. Still less do any
autopsies exist to prove its possibility. Three only have been
even quoted in connection with infantile paralysis. Of these,
the first, Clifford Albutt's, was followed by the death of the
child within a few hours, and the hemorrhage extended rather
into the posterior than anterior horns. It was never even sup-
posed to be a case of infantile paralysis, but is related by Albutt
as an example of the way in which such disease might be pro-
duced, had the hemorrhage taken place into the lumbar instead
of cervical cord, where it so soon proved fatal. In the second
case, Hayem's, paralysis had indeed occurred at two years,
and the autopsy was made long after; but then the blood was
found to have been infiltrated through the gray substance, as in
cases of central, though here localized, myelitis. Finally, in
Hammond's case a clot is said to have been found in the an-
terior column, but the examination of the cord was insufficient
to decide on the coexistence of inflammatory lesions.

274 Mary Putnam Jacobi

Among all the questions relating to infantile paralysis, the
theory of spinal hemorrhage is the one that would seem to be
most susceptible of elucidation by experiment. Vulpian," in
1861, injected lycopodium powder into the anterior crural ar-
teries of a dog, and, in several cases, found the vertebral and
spinal arteries obliterated, and real softening with hemorrhage
produced in the corresponding portion of the cord. These experi-
ments should be repeated; they show how hemorrhage might
be produced, but as they connect it with an increase of local
arterial tension caused by circumstances that are not imitated
pathologically, they do not really throw much light on the ques-
tion which immediately occupies us. From review of the pre-
ceding considerations, therefore, we must exclude the hypothesis
of congestion or hemorrhage from the pathogeny of the great
majority of cases of infantile paralysis. But in the cases of
which we have made a class apart, as characterized by the
presence of peculiar symptoms, these very lesions may very
probably exist.

These exceptional symptoms were complete though tempo-
rary anaesthesia, hyperaesthesia, retention of urine, and, in one
case, opisthotonos, all indicative of more extensive affection of
the central axis of the cord than can be possible in cases of purely
motor paralysis. They are, in fact, the symptoms of acute but
circumscribed myelitis, involving the whole axis of the cord,
and possibly, therefore, complicated with minute hemorrhages.
All the cases of spinal paralysis occurring in the adult, even
when resembling infantile paralysis in every other particular,
have differed by the presence of more or less pain; also a proof
of the wider though temporary generalization of the morbid
process.

The variations in the amount of constitutional disturbance,
at the period of invasion, imply further variations in the ex-
tension of the morbid process, even when limited to the motor
elements of the cord. The autopsy made by Prevost, as also
those by Roger and Damaschino, shows that altered cells and
blood-vessels may be found scattered through a great extent of
the gray substance of the cord, amidst elements perfectly healthy,
and far removed from the foci of paralysis. These alterations
indicate an original generalization of the affection, from which

■ Gaz. Hebd., 1861.

Pathogeny of Infantile Paralysis 275

the majority of the elements subsequently recovered, with con-
sequent limitation of the paralysis. Constitutional disturbance
was in proportion to the number of elements affected at the
moment of invasion, not to those remaining permanently injured.
From the fact observed by Duchenne fils, that fever was less in
proportion as the child was younger, it should be inferred that,
at an early age, morbid communications between the cells of nerve
centres are less facile than at a later period, when they have
become habituated to coordinated physiological action. Com-
munications between cells must depend on different conditions
than those which regulate communications between nerve cells
and nerve fibres. The originally peripheric development of the
nervous system, and the incomplete elaboration of the cellular
masses of the nerve centres at birth, would explain why the
former mode of transmission should be so ready, the latter so
much less frequent; explain the tendency, on the one hand, to
reflex irritations, and on the other, to minute localization in the
spinal paralysis of children.

It has been demonstrated by Gerlach, and quite recently by
Boll, that the prolongations of motor cells may be traced into
direct communication with the axis cylinders of the nervous
reticulum from which spring the anterior roots, while between
the posterior cells and roots the communication is only inter-
mediate. This fact may explain why, for a long time, morbid
processes are communicated to nerves from the anterior more
readily than from the posterior nerve cells; or, in other words,
why in the child paralysis is more readily produced than pain.

We speak thus confidently of motor cells, because by exclu-
sion we have been already left to localize in them the morbid
process, functional or organic, that is the immediate cause of
infantile paralysis. The considerations in regard to congestion
and hemorrhage should have served to show that the morbid
process was at least not dependent upon them, or consecutive to
any vascular lesion. It only remains, by reference to those au-
topsies which have revealed some lesion of nervous elements in
the cord, to ascertain, if possible, which among them may be
considered primitive, and if it be the motor cells, to what known
lesion or functional alteration the loss of their properties may
be due.

Four different cases exist, alike in but one point — the coinci-

276 Mary Putnam Jacobi

dence of muscular atrophy. In the first, the motor nerves alone
(cases of Elischer) or of the nerves and a corresponding portion
of the spinal cord also, were simply atrophied (cases of Hutin
and Longet). In the second, the anterior columns and roots
were sclerosed, without other lesion (cases of Laborde), or to-
gether with atrophy of the nerve (case of Cornil). In the third,
the motor cells are pigmented, as in Gombault's case of adult
paralysis, or atrophy, and disappear. Such atrophy, with sclero-
sis of the cornua without sclerosis of the columns, was present
in six autopsies. Finally, in the fourth case, complex lesions
are present, atrophy of the cells, dilatation of blood-vessels,
fatty degeneration of their walls, fasciculated sclerosis, atrophy
of nerves. Of these lesions, the atrophy of muscular fibre may be
caused by any irritation of its motor nerve. When Erb crushed
the nerve of a frog by a ligature, the nuclei of the muscular
sarcolemmae began to multiply in two weeks, and the fibre to
waste while retaining its striations, its place being supplied by
hyperplasia of connective tissue. And muscular atrophy is
known to be a common consequence of traumatic lesions of
nerves.

But in infantile paralysis the nerve has suffered no trauma-
tism, yet, when examined, was usually found to have itself
atrophied. Such atrophy can only result from a successive
series of structural alterations, similar to those which invariably
follow upon section of a nerve. It has been shown that the
phenomena resulting from section of a nerve, especially the
rapid abolition of faradaic contractility, can only be imitated
by an abolition of the properties of the motor cells at its central
end, and that when in these circumstances no condition existed
capable of interrupting the conducting power of the nerve, it
must be presumed that motor force had ceased to be generated.
The nerve atrophy must therefore depend upon some affection
of the motor cells, that must have persisted long enough to pro-
duce it ; and the rapid muscular atrophy indicates that the nerve,
either before wasting or during the process of wasting, had been
irritated. As no cause for such irritation exists in the track of the
nerve, it must be looked for in the motor cells; and hence these,
either before or during the process that resulted in their abolition
of function, must have been the seat of a peculiar irritation.

But irritated cells are in a condition of exaggerated nutri-

Pathogeny of Infantile Paralysis 277

tive activity, that determines to them a local afflux of blood, and
we have already seen that in the spinal cord no other cause for
such minutely localized congestions could be assigned, except
excited cellular activity. To this, therefore, must be attributed
the dilatations and varicosities of the blood-vessels. The fat
granules in their lymphatic sheaths result from metamorphosis
of nutritive material, no longer needed by atrophied cells.
Finally, while atrophy of nerve roots is associated with atrophy
of nerves, and may be considered as an effect of this, or as a
coincident lesion, due to the same cause; atrophy and fascicu-
lated sclerosis of the columns of the cord, are invariably asso-
ciated with irritative processes in the cells of the corresponding
cornua, posterior sclerosis in tabes dorsalis, anterior sclerosis
in myelitis, in such cases of wasting palsy as are associated with
central lesion, and in many of the cases of infantile paralysis
where lesions of the anterior cells were demonstrable. It is to
be inferred, therefore, that it depended on similar cellular irri-
tation even in the cases where lesions of cells were no longer
demonstrable at the autopsy, as in the three where antero-lateral
sclerosis was the only lesion found.

The various alterations of tissue must, therefore, each be
ascribed to an irritation of the anterior or motor cells of the
cord, and by this reference to a unique morbid process these
varieties are easily reconciled. The differences are explained
by an arrest in the morbid process at different stages of its
evolution. At any stage such alterations of special elements
might be produced as would permanently oppose restoration of
function, even though the cells failed to degenerate. Thus, if
during their period of irritation sufficient irritation had been
propagated to a motor nerve to initiate morbid processes result-
ing in its atrophy, or in that of the muscular fibre, return of
motion would be impossible, even though the cells, original
source of the disorder, regained their functions. In the same
way, a sclerosis that began to develop in the antero-lateral
column while there were no motor impulses to be transmitted,
would oppose a permanent barrier to their transmission when
the generation of motor forces recommenced.

Finally, in regard to autopsies so completely negative that
even the nerves and muscles were found intact, we may say that
none such are recorded, for in all four cases the muscle had

278 Mary Putnam Jacobi

atrophied, in two the alteration of nerve was also extremely
marked; in the remaining two there is no mention of the nerve.
Indeed, at present, the motor nerves are less frequently exam-
ined than the cord, or at least with less care, so that lesions are
more often overlooked.

The lesions discovered in the motor cells, therefore, indicate
the nature of the morbid process as decidedly in the cases where
they are absent, as in those where they are found. Cellular
atrophy is a proof that the molecular nutrition of the cells has
been arrested. It is evident, however, that the abolition of
function, so nearly sudden, must coincide with the first distur-
bance of nutrition, and not only with its ultimate consequence,
cell atrophy, which must be accomplished gradually. While
it is as conceivable that the chemical metamorphoses in the cell
may be instantly arrested by means of an impression conveyed
to it by a nerve, as that the chemical processes going on in a
solution of inorganic salts should be arrested by the passage of
a current of electricity. Both cases illustrate the now familiar
law of the correlation of forces, of the relations between chemical
affinities and electrical or neural actions.

The alterations of motor cells in infantile paralysis serve ^
therefore, as a point of transition between so-called functional
disorders and so-called organic diseases, and show with exquisite
precision the manner in which alterations of tissue may be de-
termined by perversions in the nutrition of cells.

Cases other than those of infantile paralysis are not alto-
gether rare, where the annihilation of function in important
nerve cells has been so complete, that death has occurred in a
few days, and before atrophic lesions had had time to develop.
Tetanus has long been a familiar example, and here, as in in-
fantile paralysis, more accurate microscopical researches are
beginning to discover lesions of the cord, when life has been
sufficiently prolonged. Certain curious cases of acute ascend-
ing paralysis fall under the same category. In the one related
by Pellegrino Lewins in the Archives Generates for 1865, the
death is probably due to annihilation of the functions of the
brain. But another quoted in the thesis of Petit fils, where the
autopsy was made by Comil and Ranvier, is more conclusive.
In the midst of apparent health occurred a sudden paraplegia,
accompanied by fall of temperature and analgesia in the affect-

Pathogeny of Infantile Paralysis 279

ed limbs, pain in the lumbar region of the back, abolition of
reflex movements. Anaesthesia without paralysis extended to
the upper extremities, and death supervened on the fifth day in
cyanosis, from failure of the motor forces of respiration. The
most careful examination of the brain and spinal cord could
discover no lesion, even microscopic.

In regard to the manner in which the nutrition of the ante-
rior cells may be arrested, it is well known that two theories are
in presence. According to one, a peripheric irritation causes
a spasmodic "reflex" contraction of the blood-vessels of the
spinal cord. According to the other, this irritation is directly
propagated, by means of an afferent nerve, to a cell whose nutri-
tive metamorphoses are arrested, as might be the chemical reac-
tions in a retort by the passage of an electric current. The
clearest expression of this theory has perhaps been given by
Mitchell, in the paper contributed to this polemic by him,^ and
reindorsed in his recent book, On Injuries to Nerves. " It appears
to him possible that an injury may be competent so to exhaus^
the irritability of the nerve centres, as to occasion more or less
permanent loss of function. A strong electric current is cer-
tainly able to cause such a result in a nerve trunk; and reflect-
ing on the close correlation of the electrical and neural force,
it does not seem improbable that a violent excitement of a nerve
trunk, however brought about, should be able to completely
exhaust the power of its connected nerve centre. . . . There is
no reason why, if shock be competent to destroy vitality in
vaso-motor nerves or centres it should be incompetent to so
affect the centres of motion or sensation." Handfield Jones ^
declares as the result of many clinical observations, "that any
afferent nerve may act as an inhibitory nerve upon the centre
or centres with which it is connected, disordering or paralyzing
its action." In the first number of his Archives, Brown-Sequard
has detailed many illustrations of such inhibitory actions, af-
fected by the most diverse sensitive nerves on the most different
central ganglia. Eulenburg quotes the experiment of Lewisson,''
who by strong irritation of the cutaneous nerves of a frog, sus-
pended motor power, not only in the irritated limb, but in the

' New York MedicalJournal, 1866. See also Jaccoud, Paraplegic et V Ataxic.

' Functional Nervous Disorders, pp. 9 and 16, 1870.

^ Lehrbuch, p. 428, quotes Archiv. Reicheri and Dh Bois-Reymond, 1869.

28o Mary Putnam Jacobi

others, and considers it a proof that the centripetal irritation of
sensitive nerve is sufficient to arrest the functions of the nerve
centres. The anatomical facts of infantile paralysis show-
finally that the function of such centres is arrested by inter-
ference with the chemical processes in the nutrition of the nerve
cells.

The immense pathological importance of the study of infan-
tile paralysis may be best appreciated by enumerating its dif-
ferent pathological relations, which the foregoing pages have
tried to set in relief.

I St. It links together tne most conspicuous external deformi-
ties, involving entire limbs, with lesions of internal microscopic
groups of cells, so minute as, until recently, to have escaped
observation.

2d. By exquisite localization of pathological lesions it con-
firms the doctrine of localization of function and independence
of morbid processes in special groups of nerve cells.

3d. It helps to establish a group of diseases bearing various
relations of cause or effect to this same group of cells — the
anterior spinal — as adult spinal paralysis, progressive muscular
atrophy; finally, even bulbar paralysis, where the disease is
confined to the groups of motor cells in the medulla.

4th. With these others it helps to show the immense and
peculiar influence exercised upon the nutrition of muscles by
the nerve cells influencing their motor nerves. This influence
is in both resemblance and contrast with that exercised on the
nutrition of the skin and subcutaneous tissues by the groups
of cells connected with the posterior roots and sensitive nerves.
Lesions of these produce eschars, as of those, atrophy, sclerosis,
or fatty degeneration.

5th. As a localized myelitis, certain cases, at least, of in-
fantile paralysis are to be considered in their relations to other
forms of myelitis, localized or diffused, parenchymatous or
interstitial. They are to be contrasted with cases of tabes dor-
salis, in which the myelitis localized in the posterior comua
determines a fasciculated sclerosis of the posterior columns, rela-
tively more frequent and important than the anterior sclerosis,
contrasted also with the anterior lesion of wasting palsy, which,
from the slow march of the disease, may often depend on an
extension of irritation from the periphery; contrasted with acute

Pathogeny of Infantile Paralysis 281

diffused central myelitis, with equally rapid march, but where
the lesion involves both neuroglia and nervous elements.

6th. As originally confined to the latter, the lesions of infan-
tile paralysis offer one of the best illustrations of the "parenchy-
matous inflammation," long ago described by Virchow.

yth. By its sudden invasion infantile paralysis is symptoma-
tically allied to such accidents of the vascular system as conges-
tion or hemorrhage. But as these are shown to be either ab-
sent or rare, or consecutive to an affection of nerve cells, the
capacity for independent morbid action possessed by these latter
receives another confirmation.

8th. These affections serve as a link between the so-called
reflex or inhibitory paralysis and those dependent on marked
lesions of the cord.

9th. Finally, they trace minutely the successive steps in a
morbid process that, beginning in a functional alteration of
cellular nutrition, terminates in organic destruction of tissue,
and thus dissect apart the complex phenomena both of inflam-
mation and of general cell life.

APPENDIX

To the cases described in the preceding pages, I am enabled
to add another, observed since the reading of the paper.

On the 1 8th of February a paralyzed child died at Dr.
Knight's hospital, whose history was as follows. When a year
old, the boy had had an attack of dysentery, and on recovery
was found to be paralyzed in all the four limbs, and even in the
muscles of the neck and back. These regained their power
first, so that after a few weeks, the child was able to sit; then
recovered the use of his arms, but the paralysis persisted in the
lower extremities, being most marked on the left side below the
knee. Admission to the hospital eight years later with para-
plegia and atrophy of the paralyzed limbs. There was then
not the slightest reaction to galvanic or faradaic electricity on
the left side, but some response to the induced current was ob-
tained on the right. The general health of the patient was ex-
cellent, and remained so to the day of his death. On the morn-
ing of that day he arose at 5}/^, still apparently well; at 63^
vomited, and was found sitting down in a corner of the ward,
complaining of feeling ill. While the attendant was questioning

282 Mary Putnam Jacobi

him, he suddenly turned pale, fell forward on the floor, became
almost instantly pulseless, and in five minutes was dead.

The autopsy was made by Dr. Janeway in the presence of
Drs. Knight, Gibney, Milner and myself. The paralyzed limbs,
spinal cord, and brain were all examined with care. The muscles
of the left leg were almost entirely converted into fat. The
right gastrocnemius was equally fatty, but the deep muscular
layer was tolerably preserved. To this fact was due the degree
of electrical reaction that had been observed during life, as also
a certain amount of voluntary control of the limb.

The cervical region of the cord was somewhat injected, and
a little blood was infiltrated between the dura mater and the
arachnoid. This came from the cranium. In this same region,
careful inspection showed that the antero-lateral column was
somewhat diminished in size on the right side. In the lumbar
region, on the contrary, the atrophy existed on the left side, and
by the aid of a magnifying glass was seen to extend to the left
horn of gray matter.

It has not yet been possible to make the microscopical ex-
amination, but its results will be published as soon as obtained.

The cause of death was found in the brain. A hemorrhage
had taken place into the left posterior lobe of the cerebellum.
About an ounce of blood was contained in a cavity the size of a
walnut. Blood had fused along the base of the brain to the
anterior fossae, and also, as before observed, had descended into
the spinal membranes. The entire brain, and especially the left
half of the cerebellum, was much injected.

The first symptoms presented by the child evidently coin-
cided with the commencement of the hemorrhage, and when the
effused blood became sufficient in quantity to press upon the
medulla (with which, at the autopsy, the outer edge of the clot
was found almost in contact), death occurred, with the choc en
avant, so characteristic of sudden lesions of the medulla or cervical
cord. Examination (by Dr. Janeway) of the blood-vessels of
the cerebellimi, found them extremely fatty.

Fatty degeneration of the encephalic blood-vessels, and hem-
orrhage into the cerebellum, are lesions so rare in a child of nine
years old, as already to render this autopsy of especial interest.
But more important for our present purpose, is the examination
of the cord in a case of paralysis dating from infancy, and that.

Pathogeny of Infantile Paralysis 283

even before the mcroscopical examination, can already be said
to show the lesions now to be considered as characteristic, namely,
atrophy of the antero-lateral columns, and of the anterior cornua.
Nevertheless, we doubt that this case can be claimed as a type
of Infantile Paralysis. A general paralysis after a febrile disease,
as dysentery, may, with at least as much probability, be attribut-
ed to primitive degenerations of the muscles, to which the
atrophy of the motor elements of the cord was only secondary.

REMARKS UPON THE ACTION OF NITRATE OF SILVER
ON EPITHELIAL AND GLAND CELLS.'

READ AT THE MEETING OF THE NEW YORK STATE MEDICAL
SOCIETY, 1874.

Mr. President: When I learned that I was to have the
honor of being present at this meeting of the Association, I hoped
to be able to submit to it and to you the results of some extensive
experiments upon the topical action of medicines. These experi-
ments I have indeed begun, but have been unavoidably hindered
in carrying them far enough to arrive at many satisfactory re-
sults. Instead, therefore, of a memoir worthy of your attention,
I am able only to offer a brief note upon a few details that, how-
ever, I trust are not devoid of interest.

The importance of topical medicine will always vary, in
public esteem, according to the stress that is laid upon local
diseases. There have been many periods, in the history of
medicine, when the attention of physicians was so much absorbed
by the general forces of the economy, that local diseases, or local
manifestations of constitutional disease, were neglected. It was
assimied, or rather it has been asstuned more than once, that if
the unknown vital forces were restrained, or sustained, or
encouraged, or depressed, or stimulated, or purified, that visible
lesions would disappear of themselves. Even when local treat-
ment was used, it was often only for the purpose of attacking the
general principle at a presumably vulnerable point. Hence the
eulogiums passed upon the value of aromatics and balsams in the
treatment of wounds. These famous remedies were designed
not to heal the wound directly, but to revive the vital spirits

2 Reprinted from the Transactions of the New York Staie Medical Society,
1874-

284

Action of Nitrate of Silver 285

fainting because of it. To-day, aromatics are replaced, by dis-
infectants, or only retained in virtue of a disinfectant property
which they may perchance possess. The wound is regarded, not
merely as the gaping door through which the soul may be
breathed forth towards Hades, but as an active focus of infection,
from which may flow inwards a constantly rising stream of
poison. The efforts of modern medicine are directed, wherever
possible, less to the sustenance of vital force than to the destruc-
tion of the agents by which such force may be destroyed. In the
history of an immense number of diseases, therefore, the atten-
tion of the physician is to-day, and most profitably, directed to
one of two points: ist, the existence of a focus of infection; 2nd,
the existence of a drain. To the destruction of the one, or the
closure of the other he bends his most powerful energies. I need
scarcely recall the specific cases that illustrate most strikingly this
present attitude : that surgical and puerperal fever are regarded
as the results of local auto-infection; that the dangers of osteo-
myelitis are known to be those of pyaemia; that to the reabsorp-
tion of pus is attributed the principal danger in small-pox; that
even tuberculosis has been traced to a local origin in cheesy
deposits, sometimes unique. On the other hand, the importance
of chronic inflammations and suppurations as permanent drains
upon the system, can only be adequately appreciated when as
has been done, the exuded material has been analyzed, and its
composition compared with that of the blood and tissues whose
nutrition it exhausts It is in this way that a chronic bronchial,
intestinal, or uterine catarrh may be justly compared in its
effects to a chronic albtuninuria.

Catarrhal inflammations are among the most frequent of all
diseases, and interest the localist because of the definite changes
in anatomical tissues they offer to his observation; and interest
the constitutionalist by reacting upon the general system in three
ways. They are a door of drainage, a point of irritation, and,
when acute, are frequently also a focus of auto-infection. To-
day nearly all of this class of diseases are treated by topical
medication, and this is intended, or desired, even when its
application has not yet been rendered possible.

It is evident that every substance directly applied to a tissue,
in order to modify the nutrition of that tissue, can only be handled
to complete advantage when its precise action upon each of the

2 86 Mary Putnam Jacobi

elements has been demonstrated. A complete demonstration —
chemical, physiological, and morphological — is very far from
being at present in our grasp for the majority of tissues or medi-
cines. But the morphological changes, or the alterations of form,
in the elements, submitted to the influence of the drug, are, in
many cases, easy to observe under the microscope.

Of all elements whose reaction to topical medicines is interest-
ing to us, that of the various epitheliums is most intensely so.
"All the surfaces of the body which are in contact with the
external medium, as the skin, respiratory passages, digestive
tube; all which inclose blood or lymph; all the walls of closed
cavities, serous, glandular, sensorial, are, with rare exceptions,
lined by the cells variously known as epidermic, endothelial,
epithelial — the latter spherical — cylindrical, pavement, as the
case may be."^ Everjrthing that passes into the blood, and
everything that passes out, must traverse one or more layers of
epithelium. Upon its integrity, therefore, depends the nutrition
of the entire body. No mucous and no serous membrane can
become inflamed without involving at the outset this almost
ubiquitous tissue. A large nimiber of skin diseases depend in the
morbid changes to which it is liable. It prevents or facilitates
the absorption of many miasms or specific poisons, and its morbid
reactions furnish the most delicate tests for their elimination.
The characteristic products of many diseases are principally
masses of degenerate epithelium; thus the exudation that blocks
the alveoli in many forms of pnetunonia, the casts of nephritis,
the dejections of cholera. Nor is the interest of epithelium
diminished when we examine its history, and the part it plays in
the normal or pathological genesis of tissues, since Waldeyer has
traced the ovule to an epithelial cell, and Thiersch believes to
have demonstrated the origin of cancer in epithelial tissue.

Among topical medicines most frequently used, there is one
that, in researches remote from therapeutics, has been shown to
exercise a special action upon epithelial cells. I allude to nitrate
of silver. In therapeutics this drug is used to meet three classes
of indications: to modify inflamed mucous membranes; to des-
troy morbid tissue; finally, after absorption, to arrest functional
or organic diseases of the nervous system. This last indication is
also among the most ancient discovered ; for, as Charcot and Ball

■ Farabeuf. De VEpiderme et des Epitheliums. 1872.

Action of Nitrate of Silver 287

remark, "the use of nitrate of silver was only generalized after
the promulgation of the theory of microcosm and macrocosm, in
which every terrestrial metal was made to correspond, on the one
hand, to a celestial body, on the other, to some organ of the
human frame. It was on account of the mysterious trinity
which united silver to the moon, and the moon to diseases of the
brain, that salts of silver were used in the treatment of nervous
affections."*

The practice continues in modern times, but is to be justified,
if at all, upon far other grounds. Ranvier has treated nerves
with a solution of nitrate of silver, containing i part of the salt
to 300 of distilled water. This was poured upon the nerve
before removing the latter from the body. In a few minutes
the nerve, which was translucid and elastic, became opaque and
rigid. It was washed and examined in glycerine. At a low
magnifying power could be distinguished, ist, the sheath of
connective tissue, lined with large pavement epithelium; 2d, a
number of little black crosses, studding the surface of the nerve.
With a magnifying power of 600, the vertical branch of each cross
was found to consist of the cylinder axis of a nerve fibre, black-
ened to the extent of the figure, by a deposit of silver; and the
transverse branch was formed by a ring of silver deposit, sur-
rounding the nerve fibre, and partly strangulating it. Although
not yet demonstrated, the dilution of the agent used to deter-
mine this effect, renders the topical application in some degree
comparable with internal administration, when the silver brought
to the nerve tissue shall have been diluted by the whole mass of
the blood.

The action of nitrate of silver upon mucous membranes is gen-
erally and curtly described as "astringent," and due to its prop-
erty of coagulating albimien. The caustic action, admitted to be
very superficial, is interpreted as an exaggeration of this astrin-
gency. Not only the albumen of surface secretions, but the
albimiinous constituents of tissues, it is said to be coagulated;
their vitality is arrested and an eschar formed. As a catheretic,
nitrate of silver is particularly praised on account of the precise
limitation of its action, and because the dense coagulum it forms
seems to constitute an effectual barrier to its reabsorption. Now
we shall have occasion to show that a strong non-caustic solution

» Diction. EncycL, vol. vi., p. 63.

288 Mary Putnam Jacobi

of nitrate of silver may form precisely such a barrier, while on
the other hand, the phenomena of reaction that occur beneath
and around the eschar really extend its influence to a considerable
distance. Few microscopic researches have been made on this
subject as yet, but two series of experiments have fallen under my
notice, whose bearing on this point is important. The first
experiments to which I allude are by Alexander Stuart, and are
described in the first volume of Schultze's Archives. Stuart
cauterized the thigh muscles of a living frog with nitrate of
silver to the extent of half a square centimetre in width, and one
centimetre in depth. Two classes of alterations were seen,
those representing the pure chemical action of the caustic, and
others, the result of the secondary inflammation. At the point of
cauterization the muscles assumed a diaphanous white color, and
the muscular fibres degenerated to a granular or finely fibrillar
mass, distending the sarcolemma. This mass presented all the
chemical characters of coagulated albtmien.

The non-cauterized muscular fibres exhibited various changes,
progressing towards the final conversion of their protein sub-
stance into fat. The transverse stratum appeared white and
faint, the color was transparent and whitish, sometimes opal-
escent. Chemical alterations (which I will not stop to detail)
preceded definite changes in form. Later, granules appeared,
destined to become fat; the sarcolemma thickened, the nuclei
increased in size, and ultimately proliferated. These changes
were accomplished in from two or three weeks. The fibres
became completely fatty in from two to three months.

The other experiments to which I have referred are those, so
famous, of Cohnheim, who applied nitrate of silver to the tongue
of the living frog. His observation was directed principally to
the changes in the blood vessels. His observations are so widely
known that I will only briefly recall them. In the zone immedi-
ately surrounding the eschar, the arteries leading to it rapidly
dilated; then the veins and capillaries. The circulation at the
same time is accelerated. Then the vessels feel the effect oi the
obstacle offered to the circulation by the eschar, and in those lead-
ing directly to it ; the circulation slackens, and finally stagnates as
far as the nearest collaterals, and in these the acceleration of cir-
culation continues. These alterations are purely mechanical.
In an hour or two after the application of the cautery the dilated

Action of Nitrate of Silver 289

arteries most remote from the eschar begin to contract, and the
calibre as well as rate of circulation is restored everywhere except
at the point of cauterization, and two zones surrounding it. In
the inner of these two is complete stagnation; in the other,
persistent dilatation of all blood vessels; after six and eight
hours begins the diapedesis of white and red blood corpuscles.

Cohnheim observes that other caustics, as potassa, or nitrate
of mercury, act in the same way, while mechanical irritation,
unless long continued, produces a far inferior effect. The
chemical action of the caustic was more powerful in affecting
the coasts of blood vessels. These experiments are quoted
merely to show with what limitations we may accept the dictum
that the effects of lunar caustic are precisely confined to the point
at which it is applied. Therapeutically, such microscopic observa-
tions are of value, when we are called upon to judge such
propositions as that of leaving a piece of solid nitrate of silver
to melt in the cavity of the uterus. It is certain that the action
immediately produced by lunar caustic only represents a portion
of its action; the secondary effects on surrounding tissue are more
important, sometimes more beneficial, often more dangerous.
Among all the mucous membranes that have been treated in all
variety of ways with nitrate of silver, that of the neck and body
of the uterus is certainly the most often in cause. The cauteri-
zation of the pharynx and larynx with concentrated solutions,
or with saturated spray, are equally familiar applications; the
alleged introduction of nitrate of silver into the bronchial tubes by
means of the probang, is one of the most piquant details in the
history of the nitrate, perhaps in the history of contemporary
medicine. But it is not my object to enumerate the various
indications for utilizing the action of nitrate of silver upon
mucous membranes. I wish merely to compare certain details
of this treatment with details in the microscopic preparation of
the same tissues. It is well known that when fresh membranes,
covered with epithelial or endothelial cells, are bathed for a few
minutes in solutions of nitrate of silver, that these cells are
distinctly outlined by intense black borders corresponding to
their natural boundaries. To obtain this effect it is necessary
to use extremely dilute solutions. Klein recommends one part
to two hundred or four hundred of water. Robinski uses solu-
tions of one part to five hundred, to eight hundred, or even to one

290 Mary Putnam Jacobi

thousand; and the latter preparations are preferred by Alferow.
This fact is of importance for our purpose, for it renders the result
of the direct application of silver salts to epithelium in some
respects comparable to those that we might look for when it had
been absorbed from the stomach, and brought to the tissues
diluted by the whole mass of the blood. No single therapeutical
dose, it is true, would give even this proportion;^ but it is the
property of many mineral substances to accumulate in tissues,
and this is well known to be pre-eminently true of silver. This
remark by the way. By whatever mechanism the black silver
lines may be produced, the service that their discovery has
already rendered to histology is immense. The paths of lym-
phatics have been traced more delicately than even by Sappey's
injections; and if we may believe Recklinghausen, Auerbach and
Klein, the ancient views on the structure of lymphatics have
been revolutionized, since all are shown to possess an epithelial
lining. Stomata 'have been discovered on serous membranes,
analogous to those on the epidermis of plants, and leading like
them to sub^epithelial spaces. New dangers — or rather more
adequate explanation of old dangers — have been found in
inflammations of these membranes, now viewed as immense
lymph sacks; and the tendinous centre of the diaphragm has
been invested with a special function of absorption hitherto
unsuspected. This silver method has been used by Cohnheim
to demonstrate the passage of red corpuscles between the endo-
thelium of blood vessels, and by Alferow to test the passage of
white corpuscles between the endotheliiun of the mesentery.
We have just seen what application has been made of it
by Ranvier. It would seem, therefore, that the new role of
nitrate of silver in histology bids fair to rival its ancient prestige in
therapeutics.

We have mentioned the fact, so well known, that when very
dilute solutions of nitrate are used, and are only in contact with
the membrane for a few minutes, and this only exposed to the
light for a few seconds, that the black deposit occurs only on the
boundary lines between the cells. But with eveiy increase in
the strength of the solution, in the prolongation of its contact, or
of the subsequent influence of the light, the coloration extends

'With i8 lbs., or 147,040 grains (18 X 16 X 480 = 147,040), Therap. in-
ternal dose = i to I gr.

Action of Nitrate of Silver 291

toward the centre of the cell, invading the nucleus, If at all, the
very last. Sometimes, as in the mesentery of the frog, the
nucleus remains clear in the midst of a uniformly brown cell.
His has said that on the cornea a weak solution of nitrate of
silver produced a deposit within the cornean corpuscles; while
with a strong solution these remained pale and colorless and the
deposit was formed in the intercellular substance. Schweiggel
Seidel attributes the lines to a precipitation of albimiinous fluid
lying in furrows between the convex surface of the cells. Klein
and, I believe, Recklinghausen, explain them by precipitations
in an intercellular albuminous substance that holds together the
individual cells.

Robinski denies the existence of this substance, and considers
the lines to be an optical effect due to the position of the cells.
These are uniformly colored from the beginning, but according
to Robinski, this coloration must appear more intense first upon
the edges because these are seen.

For our purpose it is essential to estimate the effects of the
deposit, within or without the cells, upon their vitality and
detriscence. It cannot be determined, a priori, whether the
partial coagulation of an albimiinous intercellular substance
should retain the cells in place, or facilitate their fall; it is certain,
however, that the effects of the silver must be very different upon
living membranes and those removed from the body, and also
that it must vary extremely with the strength of the solution.
The very weakest solution used therapeutically should, from
what precedes, produce a deposit that should extend through and
color the entire cell. Whatever effect on the vitality of the cell
would be occasioned by a deposit on its edges would be compli-
cated, therefore, by that formed in its interior.

These considerations should suggest the necessity for an
immense number of experiments. Of the series that I have
sketched out for myself, I have so far only accomplished the
following:

1st. Treatment of fresh mucous membrane from stomach of
recently killed rabbi' , with one-half per cent, solution of nitrate
of silver.

2d. Administration to rabbit of one grain nitrate in a fluid
drachm of distilled water.

3d. Treatment of human uvula, immediately after excision,

292 Mary Putnam Jacobi

with a forty-grain solution of nitrate of silver, that frequently
employed in pharyngeal catarrh.

4th. Application to mucous membrane of pharynx of eight
grains solution of nitrate, and immediate excision of small pieces
of mucous membrane so bathed. Before experimenting upon
the complicated mucous membrane of the stomach I made a
certain number of preparations of the normal stomach of the
dog and rabbit. Some of these preparations I have brought with
me. They are made according to Heidenhain's method, as
described in his original memoir and exhibit the principal details
which have since been accepted in the most recent text-books on
the rabbit. A vertical section of the mucous membrane of the
stomach was said by Heidenhain to exhibit, at a low magnifying
power, four distinct parts. In my preparations, three of these
are distinct. Proceeding from the internal surface, is seen, ist, a
border, deeply colored by carmine, fringed, or irregularly sinuous
on the free edge, with outlines of cells faintly discernible; 2d, a
narrower space, almost colorless, and where the outline of cells
can scarcely be discerned; 3d, the gland tubes, Ijing parallel to
one another, separated by a little connective tissue, filled with
much larger cells, colored principally on the two walls, and leav-
ing the centre pale. The gland cells are much less colored by
carmine than is the epithelium.

In the dog, the sinuosities on the free edge are really much
deeper, but the proportion of the red border to the rest of the
tubes is much less than in the rabbit.

At a higher magnifying power (200 diameters) additional
details are perceived. First, the red border is seen to consist of
the cylindrical epithelium lining the depressions in the mucous
membrane, into which one or more gland tubes open. This
epitheliiim gradually passes into round cells, and these into
larger, more polygonal ones; the clear space below the epithelial
border is seen to consist of the latter, intermediate between the
round and the peptic cells. Finally, these latter, as shown by
Heidenhain, and afterwards by Rollet, are of two kinds — border
cells, colored by carmine, and central or principal cells, scarcely
colored. Heidenhain shows that the latter are tumefied during
digestion, while the former remain unchanged. This fact would
imply that they were the seat of the peptic secretion, while the
border cells, colored like epithelium with carmine, resemble it also

Action of Nitrate of Silver 293

in function, being analogous to the epithelial cells that exclusively
occupy the non-peptic glands of the pylorus.

In the dog I have remarked one detail, not mentioned by
Heidenhain or Rollet. The epithelial border seemed to consist
of two layers of cells, of which the external was deeply spiculated.
The lower part of the cell, deeply colored, was thus surrounded
by quite a broad, clear border. This appearance suggested an
analogy with the spicules described by Frey on' the pavement
epithelium of the mouth and pharynx, and that as in this locality
the epithelium was held more firmly in place, the clear space
below the epithelium is much less distinct in the dog; the gland
tubes larger, and the polygonal cells larger and more distinct.
The arrangement of the border cells is more regular.

These points ascertained, I sacrificed a rabbit, and immedi-
ately removing the mucous membrane of the stomach, washed it,
and left it for a few minutes in a half per cent, solution of nitrate
of silver. It was then exposed to the light for ten minutes, but
became intensely colored, the coloration increasing during the
subsequent hardening in alcohol.

On microscopic examination of sections, uncolored by car-
mine, a dark brown border was observed occupying precisely the
place of the carmine coloration; that is, the whole layer of
epithelium. In a few places could be seen that the brown deposit
was much darker around the epithelial cells than within them,
and filled up the whole of the open mouth of the gland. In some
places a brown coagulum lay in the free surface of the mem-
brane, over the epithelium, and apparently formed of coagulated
mucus. But this was by no means constant. Any albuminate
that had been so formed had evidently been removed by the
washing. The facility with which this was done implies that
the pressure of such coagulum upon the subjacent cells, could not,
as is often asserted, exercise much influence. In the colored
specimens the carmine covered the silvered epithelium, but was
very much darker in tint than usual. It was evident that the
presence of silver in the cells, demonstrated in the uncolored
preparations, did not deprive these elements of the power of tak-
ing up carmine. A brown border was formed around the cells,
and in the centre of the funnel-mouths of the tubes, as before.
The peptic cells were quite unaltered. Nevertheless, scattered
over the surface of the tubes, appeared a number of very fine

294 Mary Putnam Jacobi

black granules. These were the only sign that this dilute solution
of nitrate of silver, applicable to membranes deprived of their
vital connections, although themselves still alive, could penetrate
below the epithelium covering.

A similar fact was shown by examination of the mucous mem-
brane of the human uvula dipped in a solution of nitrate, con-
taining forty grains to the fluid ounce, or rather more than 8 per
cent. The surface became very brown, but not nearly as dark as
the rabbit's stomach, and while hardening in alcohol, a large
amount of brownish precipitate separated. The difference in
color may have been due to the difference in epitheliimi, the
dense, stratified epithelium of the uvula being more resistant
than the cylindrical cells of the stomach. But besides the con-
tact was much less prolonged. Sections showed a clear brown
border, in which the outlines of the external layer of epithelial
cells were distinctly marked. This border did not, however,
extend throughout the epithelium, four or five layers of which
remained perfectly colorless. The epithelial conjunctive tissue
and glands were entirely unchanged.

The mucous membrane excised, after painting with an eight-
grain solution (about if), gave absolutely the same results,
except that the brown border was narrower. It also, however,
was formed by the outer layer of epithelium, and not by a layer
of coagulated mucus.

All the above preparations I have brought with me.

The administration of one grain of nitrate of silver to a living
rabbit was, however, followed by quite different results. After
the first dose the rabbit did not appear to suffer, and the same
was repeated eighteen hours later. Three hours afterwards the
rabbit was found dead. This was unexpected; for although
rabbits, as being unable to vomit, are more susceptible to the
irritation of nitrate of silver than dogs, yet they are known to
tolerate much larger doses than this, at least if reached gradually.
Bogoslowsky gave a rabbit from one to ten grains daily for thirty-
six days.' At the autopsy of the rabbit the stomach offered
many symptoms of acute catarrh. It was not hyperaemiated,
but slightly grayish in spots, covered with abundant flakes that
looked like coagulated mucus, and eroded to different depths
in various places. The stomach was washed in distilled water,

* Archives Virchow, Bd. 46, 1869,

Action of Nitrate of Silver 295

the flakes placed in glycerine, the thinned mucous membrane
hardened in alcohol, and each examined.

The flakes so exactly resembled those mentioned in all
descriptions of acute gastric catarrh, and summarily dismissed as
coagulated mucus, that I had not the least expectation of finding
anything else. Great was my astonishment to find them ex-
clusively composed of large polygonal cells, arranged in coltmins
two or three thick, and in many places exactly simulating the
peptic glands, of which they were evidently the casts. The cells
were evidently much larger than those I had previously seen on a
rabbit, larger even than the peptic cells of the dog. The nucleus
was also large and remarkably distinct. The cells were partly
filled with granulated matter. So far their condition resembled
that described by Heidenhain as characterizing the period of
digestion. But the source of their irritation was seen in the
grayish color that many had assumed, as if from a very minute
deposit of silver. Many cells were perfectly clear and pale.

To a specimen of these flakes, immersed in glycerine, a very
minute quantity of tincture of iodine was added, scarcely suffici-
ent to color the solution. After this addition, the cell walls
nearly all disappeared, and instead of columns of polygonal cells,
appeared masses of very distinct nuclei. The mucous membrane
from which these flakes had exfoliated, was in many places
diminished to half or a quarter its normal thickness. Empty
spaces showed where gland cells, or gland tubes, had been. The
epithelium was everywhere absent, but in most specimens re-
mained a narrow, irregular border, deeply colored by carmine,
and seeming to represent the round cells at the base of the
epithelium. In one specimen only the highly colored nuclei of
these cells remained, the walls seemed to have been dissolved
away. The gland cells were all much larger than normal, the
nuclei distinct and intensely colored by carmine, the cells in many
places seeming to ascend from their places. On one specimen the
lower part of some of the tubes was filled with fine detritus.
None of the cells were, however, in the least colored, nor was there
the least brown or gray tint over any part of the preparation.
Whether or no the epithelium had been colored, but washed
away, was impossible to ascertain. But as there was no epithe-
litun in the flakes that covered the mucous membrane, it was
hardly to be looked for underneath them. It had apparently

296 Mary Putnam Jacob!

been completely destroyed. This difference cannot be ascribed
merely to the dilution of the silver salt, which was one and two-
third per cent, (one grain to sixty grains distilled water), a good
deal stronger, therefore, than that with which the stomach from
the dead rabbit had been treated. Yet in this case a dense
brown precipitate was formed in and around the epithelium,
which, far from exfoliating, was cemented more firmly in place,
and the effects of the nitrate were never transmitted beyond the
epithelium to the gland cells. The coloration of the cells seemed
due to simple imbibition. But on the living subject, the intro-
duction by endosmosis of the foreign substance, excited nutri-
tive reactions; through the same endosmosis of living cells, the
irritant was transmitted much further than was possible by the
imbibition in dead or dying cells. There must have been a
greater afflux of blood to the stomach under the influence of this
extensive glandular irritation, although no traces of hyperaemia
remained after death. Finally the contact of the silver solution
with the mucous membrane must have been many times repeated.
Few conclusions can be drawn from these few observations. Yet
the following may, perhaps, be justified:

1st. The action of nitrate of silver upon living tissues is
different from that exercised upon tissues whose vital connections
have been severed, however recently.

2d. In the latter case an extremely weak solution gives a
brown precipitate at the edges of the epithelial cells, and prob-
ably between them. This precipitate is formed almost in-
stantaneously. If the solution be stronger, or the contact a
little prolonged, the entire cell is colored, except the nucleus,
This is a proof that the coloration depends on passive imbibition,
and not on the vital activity of the cell. The relation of the
silver salts to the nucleus seems to be exactly opposite to that of
carmine. The weak solutions color the entire epithelitun, but
leave the glandular tissue untouched. A rather concentrated
solution produces a precipitate only in the superficial layers of
epithelium. The coloration of these layers, however, was not
more intense with a strong solution than with one sixteen times
weaker. It is possible, however, that stratified pavement epithe-
lium offers more resistance to the imbibition than do single rows
of columnar epitheliimi.

3d. The single application of a strong solution of nitrate of sil-

Action of Nitrate of Silver 297

ver to a living epithelial surface produces the same effect as the
more prolonged contact of a weaker solution, with membrane just
removed from the body. In both cases the silver forms a superfi-
cial deposit, not always extending throughout the epithelial lay-
ers, never beneath them.

4th. On the living membrane a very weak solution, whose con-
tact is prolonged, or frequently repeated, causes the deposit of
silver in or around the epithelium, which facilitates its exfoli-
ation, and consequent destruction. At least, this has been
shown to be the case with the columnar epithelium of the
stomach.

5 th. The subepithelial glandular and connective tissue is irri-
tated coincidently with, or consecutively to, this exfoliation. The
irritation of the gland elements assimies the form characteristic of
acute desquamative catarrh. There is cloudy swelling, increased
size, and more intense carmine coloration of nuclei; loosening and
even complete separation of cells, singly, or agglutinated in casts.
The casts of the peptic glands in the specimen are strictly anal-
ogous to those shed from the uriniferous tubes, when their epithe-
lium has been submitted to the influence of some irritating sub-
stance eliminated through them .

6th. The agglutination together of the cells that separated so
easily from the wall of the tube, would seem to imply that the sil-
ver was first deposited at this latter point, surrounding the gland
cells as it had the epithelium.

7th. It is noticeable that the walls oi these cells, preserved in
glycerine, were almost instantaneously dissolved by the addition
of a very minute quantity of iodine.

8th. Coagulation of free mucus by the nitrate seems to play a
very small part in its action on mucous membranes.

9th. Only microscopical examination of such apparent mucus
can decide its real nature. In the case cited, and probably in
many others, the so-called mucus consisted entirely of cells,
coming not only from the epithelium (which had disappeared),
but from sub-epithelial glands.

loth. From what precedes, it may be inferred that in thera-
peutical applications a weak solution of nitrate whose contact was
prolonged, should exercise a more powerful and extended in-
fluence upon tissues than a strong solution applied once and
immediately decomposed. In all catarrhal affections of mucous

298 Mary Putnam Jacobi

membranes it is desirable, if possible; ist, to remove proliferated
epithelium: 2nd, to remove and provide for the healthy renewal
of the diseased cell elements ot £:lands. For both these purposes
the first method should be more efficacious than the second.
The effect on blood vessels has not here been studied.

SPHYGMOGRAPHIC EXPERIMENTS UPON A HUMAN

BRAIN, EXPOSED BY AN OPENING IN THE

CRANIUM.^

Josie Nolan, aged ten, a very healthy Irish boy, had, eighteen
months previous to observation, fallen and fractured his skull in
the right fronto-parietal region. According to the mother's
account, he remained insensible for two hours; but recovered
consciousness about two hours after the fragments of broken
bone had been removed by the trepan. The mother insists that
from that time the wound healed rapidly, and that the child
presented no morbid symptoms, not even fever. The history is
evidently imperfect. At present there is an opening in the
cranial bones, 2^ inches in the long diameter, i3^ inches trans-
versely. The opening is situated in the right fronto-parietal
regions, about 2 inches distant from the sagittal suture, towards
which the long diameter is inclined at an acute angle. The open-
ing is covered by a membrane, much thicker at the sides near the
bones than in the middle. It is to be presumed that the central
portion consists exclusively of dura mater, which, near the bony
margin, is thickened by the addition of the remains of periosteum.
The centre of this membranous covering is habitually somewhat
depressed below the level of the cranial bones, but rises and falls
in regular pulsations synchronous with those of the radial artery.
Ordinarily, the effect of respiration is only distinctly seen in the
sphygmographic trace; but, on forced inspiration, the membranes
are clearly seen to descend still further below the level of the
bones, and on forced expiration to bulge above it. Pressure upon
the brain through these membranes causes no appreciable effect
even on the pulse, and the boy, who has all the activity of his
age, has, so far, never experienced the least inconvenience from

' Reprinted from the American Journal of the Medical Sciences, 1878.

299

300 Mary Putnam Jacobi

this partial exposure of the brain. Under no circumstances, of
digestion, exercise, or the influence of the various drugs admin-
istered during the experiment, was any change noticed in the
colours of the membranes indicating increased vascularity in
them. After exercise, they sometimes are bulging, but not
always, and the effect of a temporary exertion rapidly disap-
pears. When the boy is in a recumbent position, the level of
the membranes is always higher than during the vertical posi-
tion, whatever the level in the latter might be, or from whatever
cause it had been effected. ^

The case offered a unique opportunity for the study of con-
ditions affecting intra-cranial pressure. For this purpose,
Mahomed's sphygmograph was adjusted to the head of the boy,
in such a manner that the lever pad rested on the thin central
portions of the membranes, the rest upon the bones, and steadied
by an assistant. The adjustment was always made with the boy in
a recumbent position, the head but slightly elevated upon a pillow.

Before interpreting the traces, it is necessary to notice in what
respects these must be expected to differ from those obtained from
the expansion of an artery. It is obvious that the pulsating
encephalon in our case differs from the pulsating artery: ist,
by its greater proximity to the heart; 2d, by its vertical position
over the heart; 3d, by the immensely greater surface receiving
the shock of the cardiac systole, and through which must be
disseminated the tidal wave of blood; 4th, by the greater volume
of blood thrown against this surface; 5th, by the greater freedom
allowed to the excursion of the part of the brain exposed; 6th, by
the greater slowness with which its mass could collapse upon the
blood wave. The trace from the artery corresponds to the move-
ment of the entire mass of fluid contained in it. But while the
pulsations of the encephalon are due exclusively to the influx of ar-
terial blood, this fluid is only one of three which are moving simul-
taneously in the pulsating mass, the others being the venous blood
and the cephalo-rachidian fluid. 7th, the final difference to be no-
ticed in the much greater influence of respiration upon the amount

' Since writing this paper I have seen an article in the Centralblatt for 1877,
describing analogous experiments upon a woman's brain exposed by carcinoma.
The experiments did not test the influence of drugs; but the conclusions so far
as regards the normal movements of the brain agree with mine. See Central-
blatt, Mai 12, 1877. Giacomini u. Masso, Beweg. des Gehirns.

Sphygmographic Experiments 301

of blood contained at a given moment in the brain, as compared
with that contained at the same moment in the radial artery.

These various circumstances will each have a specific effect
upon the sphygmographic trace. Thus, the first five peculiarities
enumerated will combine to give a much greater amplitude to the
curve, or an immense increase in the height of the ascension line.

Owing to the fourth circumstance, the height of the tidal
wave above the base of the percussion stroke will be greater; for,
according to Mahomed, "this height indicates the amount of
blood forced into the arterial system at each ventricular systole.*"
From the sixth peculiarity, the tidal wave should be more sus-
tained. On account of the third character, there should be few
oscillations from secondary waves; thus, dicrotic and elasticity
oscillations should be little marked. On the other hand, the
multiplication of resistances offered in the brain by fulness of its
veins, or tonic contraction of its arteries, should render obliquity
of the percussion stroke, and even anacrotismus of the ascending
line more frequent. Finally, from (seventh) the greater influence
upon intra-cranial circulation exercised by the aspirating force
of inspiration, a much greater depression should occur at the
moment of inspiration in the ligne d' ensemble.

The foregoing characters are all exhibited by the traces.
The encephalic expansions, as uninfluenced by medicines, are
shown in Trace No. I.; also. Trace No. VI. before the adminis-
tration of atropia, and No. X. before coffee, and under the double
influence of exercise and the digestion of a full meal.

Trace I.

Under pressure 5.

Description. — Trace No. I. exhibits a peculiarity not observ-
able in Traces VI. and X.; it possesses an anacrotic elevation, or
an elevation on the ascending line. ^

' Med. Times and Gaz., vol. i., 1872, p. 129,

* Elevation first studied experimentally by Landois. Die Lehre vom
arterien Puis, Berlin, 1872.

302 Mary Putnam Jacobi

This is described by Mendel' as the character of the "pulsus
tardus." In his schema, Landois succeeded in producing "ana-
crotismus" under one of three conditions, namely, when the exit
opening of the schematic artery is narrowed ; when the elasticity
of its walls is diminished; and when, from increased volume of
its contents, the internal tension is increased. Each of these
conditions renders the distension of the tube by the systolic wave
more difficult, hence prolongs the period of distension. Eulen-
berg shows that an anacrotic elevation may be obtained by com-
pression of the artery beyond the point at which the sphygmo-
graph is applied.

The other characters of this trace are, the well-developed tidal
wave, or curve intervening between the percussion stroke and the
aortic notch, and which, according to Mahomed, indicates the
mass which has been thrown into the arteries by the cardiac
systole; 2d, the deep inspiratory depression; 3d, the dicrotic
elevation is slight, but more marked than in other traces.

Interpretation. — These characters, together with the short but
vertical percussion stroke, indicate increased cerebral resistance
with a large volume of blood in active circulation. The larger
the mass to be aspired into the thorax at inspiration, the more
marked must be the depression in the line of cerebral expansions,
or the ligne d' ensemble of the trace. ^ The slightly increased
dicrotism in the trace is to be referred to the state of the mem-
branes, which were depressed, and flaccid, not tense or bulging.
It was clear, therefore, that, notwithstanding the considerable
tidal wave, the brain was not at the time distended. In another
trace, taken when the membranes were tense and bulging,
dicrotism had entirely disappeared. It is to be inferred that the
tonic resistance of the blood-vessels was at this time great. Such
a condition would at once explain the great resistance offered
to the cardiac systole, causing anacrotismus, and the diminished
tension of the membranes, permitting slight dicrotismus. The

' Arch. Virch., Bd. 66, p. 260. See also Eulenberg, Arch. Virch., Bd. 45,
1869.

^ The percussion stroke is shorter during inspiration than during expiration.
Since at this moment the cerebral resistance is diminished, this shortening
must be due, not to increased resistance, but to diminished force of the heart.
This diminution is caused by the "negative pressure" exercised on the heart
during the expansion of the thorax, and thus is secured a real intermittence
in the blood-pressure to which the brain is subjected.

Sphygmographic Experiments 303

radial pulse showed high tension, and complete absence of dicro-
tism.

Hence, important corollary, we must conclude that intra-cranial
pressure (such as would distend the membranes) is not necessarily
in proportion to the tension of the cerebral blood-vessels, or to the
height of their tidal wave, but may be just the reverse.

Trace II.

Pressure 5, two hours after 5 grs. of sulphate of quinia. Pulse 90.

Description. — Trace No. JI. may be described as follows:
Percussion stroke perfectly vertical and very high (by exact
measurement one-third higher than in Trace No. X., the nexl
highest observed). The angle between the percussion stroke
and the line of descent of the preceding curve is very acute.
Entire absence of anacrotismus. The systolic apex forms an
acute angle, and is followed, not by a rounded curve, but by a
horizontal, even slightly concave line. The tidal wave is very
small. The line of descent is abrupt, and the dicrotic elevation
very near to its terminus. Finally, the inspiratory depression
in the ligne d' ensemble is enormous.

The membranes bulged more at each cardiac systole than
before the administration of the quinia, but were not tense.

Interpretation. — The height and vertical direction of the per-
cussion stroke are not exclusively due to increased energy of the

304 Mary Putnam Jacobi

cardiac systole, since when this is obtained by brandy the per-
cussion stroke is much lower (see Trace No. IV.). Hence, in
addition to the effect on the heart, there must be diminution of
the intra-cranial resistance. The acute angle of the systolic
apex implies an instantaneous momentary collapse of the cerebral
blood-vessels after their distension by the percussion stroke.
From the smallness of the tidal wave we must conclude that little
blood is retained in the arteries at any given time. But the
prolonged horizontal line between the systolic apex and the
summit of the tidal wave, implies a sustained tension of the
arterial walls. The line resembles that observed in traces from
atheromatous arteries. But the abrupt line of descent indicates
powerful elastic contraction of the arteries, contrary to what is
seen in atheroma.

Conclusion. — By a tonic dose of quinia, the energy of the cardiac
systole is increased; the tonus and elasticity of the walls of cerebral
blood-vessels are also increased, so that the blood is forced rapidly on
through the capillaries, thus diminishing the resistance to the cardiac
systole. More blood is admitted to the brain, but the intra-cranial
pressure is lessened.

Trace III.

Two hours after 20 grs. of quinia. Pressure 5. Pulse 96. Temperature fallen
one degree. Membranes depressed.

Description of Trace III. — Percussion stroke vertical, but
shorter than in Trace II. Systolic apex angle acute, and followed
by descending instead of horizontal line. Tidal wave unequally
developed, in some curves almost absent, in all very small, and
far below the level of systolic apex.

Interpretation. — Diminished intra-cranial resistance to per-
cussion stroke; nevertheless, small amount of blood thrown into
brain, rapid and complete collapse of cerebral arteries.

Conclusion. — Diminished energy of cardiac contractions, un-
filled cerebral arteries, great diminution in intra-cranial pressure.

Sphygmographic Experiments 305

It is important to notice that the radial pulse taken at this
time exhibited a relatively much larger tidal wave and higher
tension than was shown by these cerebral traces. We should
infer therefore that the dimintition of intra-cranial pressure was
out of proportion to the general diminution of pressure in the arterial
system comiected with sedation of the heart.

Description of Trace IV. — Percussion stroke not quite vertical,
much shorter than after quinia; systolic apex forming a right,
instead of an acute angle; tidal wave greatly developed; line of
descent oblique and gradual ; angle between it and the following
percussion stroke rather wide; dicrotism scarcely perceptible;
inspiratory depressions not very marked, and much prolonged,
comprising four curves, while the period of expiration comprises
three.

Trace IV.

Pressure 5. After 3 drachms of brandy. Pulse 104. Membranes tense

\

bulging.

The membranes were tense, bulging, and affected by a pecu-
liar heaving pulsation, not seen in any other case; the pulse was
104.

Interpretation. — Increased mass of blood in brain; increased
resistance to percussion stroke dependent on this, and less than
that which would be associated with contracted arteries; ' (see
Trace I.) slow collapse of arterial walls, notwithstanding rapid
circulation; increased duration of inspiration; slow aspiration
of blood from brain.

Conclusion is mainly expressed in the interpretation. The
increased force of the heart is indicated by the radial pulse; its
effect on the brain as shown in the trace, is partially compensated
by the increased intra-cranial resistance. The cerebral blood-
vessels are dilated, implying diminished tonus of their walls; the
intra-cranial pressure increased.

' Hence the percussion stroke, though short, is not anacrotic.

3o6 Mary Putnam Jacobi

Trace V.

After 5 gtts. tincture belladonna ter in die for four days, and 5 gtts. every three
hours on fifth day. Pulse 108. Pupils moderately dilated, mem-
branes bulging, not tense in recumbent position.

Description of Trace V. — General resemblance to Trace IV.
under brandy. Percussion stroke one-fifth higher than in Trace
IV.; systoHc apex a right or slightly obtuse angle; tidal wave
developed about as much as with the brandy; line of descent
gradual, without dicrotism; absence of inspiratory depression;
rise of entire ligne d'ensemble, as if from prolonged expiratory
effort. All the characteristics of the trace were developed un-
der a pressure of four ounces, as was not the case with brandy;
but the percussion stroke was then higher than is represented in
Trace V. The membranes did not bulge at all when the boy was
vertical.

Interpretation and Conclusions. — Mass of blood in the brain
increased about the same as after brandy; but intra-cranial pressure
less (as shown by condition of membranes, and response to lower
pressure of sphygmograph) . Expiration prolonged.

Remarks. — From the traces alone it is rather difficult to under-
stand why the tension of the membranes should have been so
great with the brandy, and so slight with the belladonna; the
rapidity of the circulation was almost the same in the two cases
(pulse 104 and 108). The difference probably depends on accel-
erated capillary circulation in the case of belladonna, and retard
of the same after brandy.

Trace VI.

Before atropia, membranes depressed.

Sphygmographic Experiments

Trace VII.

307

30 minutes after, 5*5 gr. atropia, subcutaneously. Pulse 120.

Description. — Trace VII. Half an hour after ^V gi"- atropia
shows, as compared with Trace VI., taken just before; that the
percussion stroke is double the height, and more nearly vertical;
the anacrotism has disappeared; the angle of the systolic apex
rounded, but followed by descending instead of ascending line;
tidal wave much diminished; dicrotic elevation increased, and
nearer by one-fifth to the percussion stroke — that is, the dura-
tion of the ventricular systole is one-fifth less. Inspiratory de-
pression remains the same, slightly marked, and comprising a
single curve. The membranes were raised, but neither tense nor
bulging. The radial pulse had become dicrotic.

Interpretation. — Relaxation of cerebral blood-vessels; conse-
quent diminished intra-cranial resistance to percussion stroke;
more rapid collapse of arterial walls ; diminution in mass of blood
retained in brain.

Conclusion. — Diminution of intra-cranial pressure, but in-
creased amount of blood passing through brain in given time; on
account of accelerated cardiac action and diminished resistance to it.

Description. — The peculiar effect produced by the drug is not
perceptible in any individual trace alone, but in a comparison
between the traces taken under moderate pressure (four and five
ounces. Trace IX.), or under higher pressure (six ounces, Trace
VIII.). In this the ascending stroke is anacrotic, in the others
not. The tidal wave is also much less developed.

Trace VIII.

)

Pressure 6.

Interpretation. — The increase in pressure of the sphygmo-
graph lever is transmitted to the cerebral arteries, so as to offer

3o8

Mary Putnam Jacobi

decidedly increased resistance to the ventricular systole, and
instead of developing the percussion stroke, breaks it. That
such slight increase of pressure is able to cause anacrotismus,
shows that tlie force of this systole, i. e., of the heart's action, has been

Trace IX.

2 J hours after i gr. tartar emetic. No vomiting. Membranes apparently
tense, bulging. Pulse 112. Pressure 5.

weakened relatively; that the intra-cranial pressure is not only
diminished, but is easily overcome by external pressure ; in other
words, that the walls of the arteries are relaxed. This peculiarity
is not observed in any other trace, even that of the sedative dose
of quinia, but is confined to the nauseating dose of tartar emetic.
After vomiting, the intra-cranial pressure is raised, and resists
the higher pressure of the sphygmograph.

Trace X.

Pressure 5. Before coflEee, pulse 112. Membranes tense, bulging.
Trace XI.

Pressure, 5. Half an hour after 4 oz. strong infusion coflfee. Membranes much
depressed. Pulse 112.

Description (Trace XL). — Absence of inspiratory depression,
which has been marked in Trace X. Percussion stroke shortened
to one-fifth the height, oblique, instead of vertical ; higher under

Sphygmographic Experiments 309

pressure 6 than 5. Diminution of tidal wave. The membranes
were depressed, which had been bulging. The radial pulse
remains the same in rapidity, and also in the form of the sphygmo-
graphic trace (not here given).

Interpretation. — From this last fact it is evident that the per-
cussion stroke has not been shortened by weakening the force of
the cardiac contraction. The shortening must, txierefore, be
due to an increased resistance in the brain. As there is not an
increased mass of blood in the brain, the resistance implies in-
creased tonicity — increased contraction of blood-vessels. This
tonicity is only overcome by greater external pressure; hence
percussion stroke is more developed under pressure 6 than 5
(reverse of tartar emetic).

Conclusion. — The amount of blood circulating in the brain is
smaller, but it is brought to nerve tissues under increased pressure;
hence assimilation of nutritive material should be increased in
rapidity, if lessened in quantity. The intra-cranial pressure, on
the whole, i. e., against the membranes, is diminished.

Trace XII.

Presstire 4. Three hours after twenty grains of bromide of potassium.
Trace XIII.

Pressure 5. Pulse 76; membranes depressed below cranial level.

Description. — Great development of tidal wave, perceptible
under all pressures. At pressure 4, percussion stroke so oblique
as to merge into tidal wave. Trace resembles that from an
aneurismal tumour.' Under pressure 5, percussion stroke some-
times vertical, sometimes oblique. Line of descent prolonged
and gradual, without trace of direction.

Interpretation. — The trace must be considered in connection
' See trace given by Mahomed, Medical Times and Gazette, 1873, p. 222.

310 Mary Putnam Jacobi

with the facts, that the membranes had become depressed, and
the tidal wave of the radial pulse extremely small, under the in-
fluence of the bromide. It is to be inferred, therefore, that the
large tidal wave in the cerebral trace does not depend upon an
unusual amount of blood thrown into, or contained in, the brain,
but upon unusual obstacles to its passage out of the brain. This
implies a contraction of the smallest blood-vessels and capillaries,
the larger remaining the same, and thus offering no other obstacle
to the ventricular systole than the prolonged retention of blood in
them; the latter causing increased lateral pressure, identical with
that of a large tidal wave.

Conclusion. — The intra-cranial pressure, on the whole, i. e.,
against the membranes, is diminished; but the brain tissue is sub-
jected to a mechanical pressure from fulness of the vascular canals
before the point where they begin to be nutritive, and because of
relative exclusion of the blood from the latter.

Remarks. — The descriptions of the traces of coffee and brom-
ide read a good deal alike, except in regard to the tidal wave; but
the traces are conspicuously different. The difference probably
depends on the different rate of the circulation, on the different
direct action of the drugs on the nerve tissues, and on the exercise
of lateral pressure in the nutritive blood-vessels in the case of the
coffee; in the canals leading to them, in the case of the bromide.
In the case of the brandy an increased tidal wave was interpreted
as evidence of dilatation of cerebral blood-vessels, because of the
visible increase in the tension of the cerebral membranes and the
state of the radial pulse which coexisted.

The characteristic trace of the bromide was not developed
until three hours afters its administration. It was most char-
acteristic at a low pressure (4). It is not believed that the whole,
or even the greater part of the physiological action of bromide
of potassium can be explained by this effect upon the cerebral
blood-vessels.

To what extent the conclusions, drawn from these observa-
tions, are in accordance with existing theories, may be considered
on another occasion. On this, we content ourselves with regis-
tering the facts.

ACUTE FATTY DEGENERATION OF THE NEW-BORN.^

The following case offers, we believe, an interesting illustra-
tion of a recognized, but still rare and not completely understood
disease.

Early in the past year, Mrs. H. asked my advice under the
following circumstances: She had been married twelve years, and
her eldest and her only surviving child was then eleven years old.
I have forgotten the fate of the second child. The third was
bom prematurely at seven months, and died within twenty-four
hours after birth. The fourth was apparently healthy for three
or four days, then began to have hemorrhages from the navel
which resisted the application of iron styptics, and to whose
repetition the child finally succumbed on the eighth day after
birth. The fifth child was born dead at term — a week after the
cessation of all movements. During this fifth pregnancy, Mrs.
H.'s health, which previously had been irreproachable, had
suffered a good deal, and she had noticed that her abdomen
remained much smaller than in former pregnancies. The child
at birth was said to have been very small, but no exact measure-
ments were taken. After this confinement, Mrs. H. recovered
her health completely. At no time, so far as could be ascer-
tained by the history, did she present symptoms of endometritis,
still less of syphilis. After the misfortune of the fifth confine-
ment, she was advised, by a well-known German physician of
this city, that, in the event of another pregnancy, she should
watch the movements of the child carefully, and should they,
near term, begin to grow weaker, that she should at once report
the case to a physician, who might save the child by bringing
on a premature confinement.

It was for precisely this exigency that Mrs. H. consulted me.

' Reprinted from the American Journal of Obstetrics, 1878.

3"

312 Mary Putnam Jacob!

About a year after the fifth confinement, she again became preg-
nant, and was now two weeks before term. During the period of
gestation her health had been uninterruptedly good, and the
movements of the child vigorous, until a few days previous,
when they had begun to grow much weaker, and, warned by her
previous experience, she was fearful that they might soon cease
altogether.

Upon examination I found the child apparently well-developed,
the head presenting in the first position, the amniotic liquor in
sufficient abundance, but not excess. The uterine souffle was
loud and distinct, but the most careful search failed to discover
the fetal heart, although the spontaneous movements of the
child showed that it was still alive. It was evident, therefore,
that the heart's action had begun to flag, under some unknown
morbid influence, probably identical with that which had caused
the death of the third and the fifth child. It was evident,
further, that if this lethal influence depended on any lesion of
the fetal viscera, a premature confinement would rather hasten
death than avert it; while, if it were due to some morbid condi-
tion of the placental or umbilical circulation, this expedient
might possibly save the life of the child, as, in view of the pre-
vious history, there was so much reason to suppose that the
child would die if left to itself. I determined to act on the hypo-
thesis which afforded the only excuse for action or hope of safety,
and, confirming the previous opinion, advised artificial delivery,
to which the parents readily assented. The cervix was extremely
soft and dilatable, and by means of Barnes' dilators, labor pains
were induced in about twenty-four hours. The child (a girl) was
born seven or eight hours later, and, although rather small,
seemed fairly vigorous. It cried immediately after birth, and
showed no sign of asphyxia. The cord was to external appear-
ance healthy. The placenta adhered for nearly an hour, and
then was removed by artificial detachment, and torn during the
process. But that all fragments were entirely removed from
the uterine cavity was demonstrated, if necessar3% by the rapid
and complete recovery of the mother.

In securing the cord, after the child had been washed by the
nurse, I took the precaution to apply two ligatures, as tightly as
possible. I then left the child in apparently a very satisfactory
condition, but two hours later, four hours after birth, was recalled

Fatty Degeneration of New-Born 313

by the tidings that an alarming hemorrhage had just taken place
from the cord. The nurse compressed the cord with her fingers,
and a neighboring physician, summoned while awaiting my
arrival, found that this manoeuvre had nearly arrested the
hemorrhage just before he came in. The child, however, was
perfectly blanched, and to prevent, if possible, a recurrence of
the danger, the doctor wound an elastic ligature tightly around
the cord, from its free end to its cutaneous surface, not encroach-
ing upon the latter He confirmed the statement of the nurse,
that the blood had been seen to ooze from a point above the upper
ligature, just at the junction of the mucous and cutaneous
surfaces of the cord. At this point a minute tear was
perceptible.

I did not see the child until nearly an hour after the acci-
dent. By that time color had returned, there was sufficient
warmth, and a few drops of brandy in water were readily swal-
lowed. The child was left wrapped in cotton-wool, and perfect
quiet enjoined. This was at noon.

At four o'clock in the afternoon, when recovery from the first
accident seemed complete, I resolved to take the last precaution
against its repetition, which seemed only too probable, by passing
a couple of hare-lip pins at right angles to each other through the
cutaneous base of the cord, and winding a ligature tightly around
them, as in the strangulation of a nevus. The child was not
moved from its cotton-wool nest during the little operation.
Neither at this time nor later was there any disturbance of
respiration. At six o'clock, it was doing very well; at ten, as I
entered the room, the mother exclaimed with great satisfaction
• that the baby must be growing stronger, for it had been scream-
ing loudly for half an hour, and its cries had only just ceased.
The quiet was ominous, and on approaching the child I found
that the face had again become perfectly white, and that it had
ceased to cry because it had ceased to breathe. The heart still
beat feebly, but in a few minutes its pulsations also ceased, and
life was completely extinct. Upon removing the coverings, I
found that a slight amount of oozing had again taken place at
the navel. There was none, however, around the hare-lip pins.
This slight hemorrhage seemed altogether insufficient to account
for the death. The real cause of death was revealed at the
autopsy made twenty-four hours later.

314 Mary Putnam Jacobi

Autopsy

Abdomen. — Several teaspoonsfuls of fresh fluid blood were
found in the peritoneal cavity, some lying on the surface of the
intestines, more gravitated into the flanks. There was no
hemorrhage of the intestine, either into its coats or into the
cavity. No trace of peritonitis. The blood seemed to have
come chiefly from a rupture of the umbilical vein, between the
navel and the liver, for in the connective tissue surrounding it,
about half an inch above the navel, was a blood-clot the size of
a French bean.

No hemorrhages were discovered in the liver, spleen, or kid-
neys, but minute submucous hemorrhages were scattered through
the stomach.

Thorax. — Here a most peculiar appearance was presented.
The lungs were fully expanded, and collapsed imperfectly on the
removal of the sternum. Scattered over their entire surface
were numerous hemorrhagic spots, whose pleural area varied in
diameter from a few lines to half an inch. The depth of these
foci was generally about the eighth of an inch. The deep ex-
tremity was somewhat smaller than the superficial, but in no
case did they oflPer the wedge-shape characteristic of embolic
infarcti. Similar hemorrhagic spots were disseminated through-
out the parenchyma of the lungs. Between these spots the
lung-tissue was normal to the naked eye.

There was no effusion into the pleural cavity. There were
no macroscopic alterations of the heart. The cranial cavity was
not opened.

Microscopic Examination

Umbilical cord. — The umbilical vessels were examined exter-
nally to the abdomen, and also for a short distance above and
below the internal surface of the navel. All the sections were
normal.

Liver. — Examination of sections at a low power in no case
succeeded in discovering the distinct separation into lobules,
which is usually so easy to demonstrate on the liver of a new-bom
child. At the same power, the larger bile ducts were observed
to be surrounded by tissue, colored bright blue by the hematoxy-
line, in striking contrast to the pale color of the rest of the sec-
tion. A higher power resolved these blue bands into masses of

Fatty Degeneration of New-Born 315

round nucleated cells. The liver-cells were filled with fine fat-
granules, which in no case were aggregated into globules. The
size, shape, and nucleus of the cells were preserved, the nucleus
coloring deeply with hematoxyline.

Kidneys. — The epithelium was degenerated both in the cortex
and in the medullary portion, but the process was much further
advanced in the convoluted tubes than in the straight. In some
of the tubes the epithelium was completely broken down, the
nucleus gone in others, while the cells were full of fine granules;
the nucleus was preserved and distinctly colored. The Mal-
pighian glomeruli were generally intact, but in some cases the
epithelitun covering them was degenerated like that of the tubes.
In some places, quite a large area of the microscopic section was
so completely degenerated that it appeared a uniform pale-yellow
color, no nuclei remaining to take up the color of the staining
fluid. In other places again, a small number of the tubes would
appear completely normal. There was no proliferation of
epithelium, and the lumen of the tubes was nearly always free.
The connective tissue was not increased. The blood-vessels
showed a few fat-granules in the tunica media.

Stomach. — The sections of the stomach did not show any de-
generation of the glandular cells, and were not sufficiently suc-
cessful to demonstrate the condition of the cylindrical epithelium.
On one section was found a mass of blood-corpuscles effused just
at the base of the glands. The submucous blood-vessels showed
the same sparse scattering of fine black granules between the
nuclei of the muscular coat as were found in the renal vessels.

Lungs. — Blood-corpuscles were scattered in abundance
throughout every section, sometimes aggregated into masses,
when the section had passed through a focus of hemorrhage,
sometimes sparsely disseminated. The capillaries all contained
blood, and the loops of vessels which encircled the alveoli looked
as if they had been artifically injected. In some cases, these
loops almost entirely occluded the alveolus. There was also a
great abundance of epithelium in various stages of fatty degenera-
tion. In some cases the epithelium had broken down into fatty
detritus. These appearances have been described in cases
hitherto related. But one feature in this case, of which I have
not found any previous mention, was the appearance of fat-
granules in great abundance in the muscular coat of the arteries,

3i6 Mary Putnam Jacobi

interspersed among the nuclei. These granules dissolved in ether,
and resisted acetic acid.

In two sections were discovered the point of rupture of
medium-sized blood-vessels, with a stream of blood-corpuscles
pouring through.

Heart. — The muscular fibres of the heart contained fat-
granules, but in excessive abundance.

The case above described was evidently one of the rare
disease first described by Hecker and Buhl in 1861, under the
name of "acute fatty degeneration of the new-bom." Buhl's
description' is as follows: "The lungs contain smaller or greater,
tolerably circumscribed hemorrhagic infarcti; the bronchi con-
tain pure blood or bloody mucus. The parenchyma of the limg
is somewhat edematous ; the pavement epithelium filled with fat-
granules. There is, further, fatty degeneration of the muscular
fibre of the heart, and of the epithelium of the kidneys and liver.
As a consequence of the pulmonary and cardiac lesions, the
child soon shows symptoms of asphyxia and cyanosis; and as a
consequence of the hepatic degeneration becomes icteric."
Buhl attributes the multiple hemorrhages to alterations in the
composition of the blood and the texture of the blood-vessels,
both probably dependent upon the "acute nephritis and hepa-
titis."

In the Arch, fiir Gynaek., Bd. x., Hecker describes a new
case of this disease. The child died in fourteen hours, after a
slight hemorrhage from the navel quite insufficient to explain
the catastrophe. The icterus was present at birth, and intense.
At the autopsy were found numerous subpleural ecchymoses,
large wedge-shaped pulmonary infarcti, fragility of walls of
pulmonary vessels. There was blood in the pericardium, stom-
ach, and intestine; the liver was pale and fatty; the heart soft
and fragile; the spleen enlarged. In another case, reported by
the same author, the blood was leukemic. Hecker remarked
that this disease is so rare that it has scarcely been mentioned
in literature since Buhl's first description of it was given. Miiller
in a chapter devoted to acute fatty degeneration of the new-
bom in Gerhardt's Cyclopedia, ^ only quotes five articles on the
subject; of these only two^ describe the disease in the human

' Klinikfiir Geburtskunde, 1861. ' Bd. ii., 1877.

3 Hecker u. Buhl, loc. cit., and Hecker, Monats.Jiir Geburtskunde, Bd. xxix.

Fatty Degeneration of New-Born 317

subject. Furstenberg^ describes an analogous affection in the
new-born of domestic animals. Roloff writes about young
pigs- and foals. ^ The latter case is really an acute malignant
osteitis, and has but very slight resemblance with the morbid
condition which occupies us. Muller himself contributes nothing
original to the subject.

Three symptoms are prominent in the clinical history of this
disease: umbilical hemorrhage, cyanosis, icterus; the latter
constantly increasing until the moment of fatal termination.
Of these, the first, or umbilical hemorrhage, was alone present
in our case. It occurred earlier (two hours after birth) than in
any case of which I can find a record. According to Hennig, of
all cases of omphalorrhagia, the greatest number occur on the
seventh day, that is, at or after the fall of the cord. He only
counts 7 cases out of 135, as occurring on the first day. Accord-
ing to Bouchut, the greatest frequency is from the third to the
ninth day. Tanner only mentions the cases which occur after
the fall of the cord. Although the accident is itself infrequent
(Hennig reckons it as occurring once in 5,000 children), only a
certain proportion of cases are to be attributed to generalized
fatty degeneration. The belief that the hemorrhage principally
depends upon imperfect ligature of the cord is widely diffused,
both among the laity and in the profession, and has been not
infrequently the basis of suits for malpractice. Thus Cripps
Lawrence* declares that early hemorrhage is from the funis,
and easily controlled by prompt ligation, even when the blood
comes from the side of the cord. In the latter case, the accou-
cheur is innocent of carelessness ; but the ordinary ligature must
be complemented by another on the ventral side of the bleeding
point. "With this exception," asserts the writer, "omphalor-
rhagia preceding the fall of the cord is always due to imperfect
ligature, or to imperfection in the material used for ligature, or
to improper handling of the ligatured end of the cord."

Mr. Lawrence admits that hemorrhage from the umbilicus,
which he calls secondary, is a serious and "sometimes" fatal
accident. He fails, however, to perceive that this hemorrhage
may occur before, as well as after, the fall of the cord. Braun,
in 1 87 1 , had pointed out that the main significance of umbilical

' Virch. Arch., Bd. xxix. * Hn^^^ Bd. xxxiii. ^ Ibid., Bd. xliii.

■» Obstetrical Journal, vol. iii., 1875.

31 8 Mary Putnam Jacobi

hemorrhage depended, not on the epoch at which it occurred,

but on its origin from the umbilical vessels themselves, or from
the "parenchymatous" vessels supplying the navel. The latter
always depends on constitutional disease. Similarly Vogel
describes the blood "welling up from the umbilical depression"
left after the fall of the eschar. We have said that in our case,
where the first hemorrhage took place two hours after birth,
the blood was seen to issue from a minute opening at the junc-
tion of the mucous and the cutaneous surfaces of the cord, hence
must be classified with those cases called by Braun "parenchy-
matous."

The constitutional disease to which such parenchymatous
hemorrhage has often been attributed is hemophilia. This has
sometimes been inferred merely from the repetition of the
accident in several children of the same family. Thus Jenkins*
remarks that 17 mothers, among those whose histories he had
collected, lost more than one child by umbilical hemorrhage.
The same repetition of the accident was remarked in several
children of Mrs. H. (our case). Hennig, however, observes that
the tendency to multiple hemorrhages, characteristic of these
cases, bears much more analogy to scorbutus than to hemo-
philia. Grandidier^ declares that navel hemorrhage is only to
the smallest extent the expression of the hemophilic diathesis.
It is not especially frequent in families of "bleeders," and the
children who survive the accident do not manifest hemorrhagic
tendencies in later life. Out of 228 cases of omphalorrhagia,
only 14 come from "bleeders," belonging to 11 hemophilic
families. The bleeding diathesis is 13 times more frequent in
males, but omphalorrhagia is more frequent in female children.
The evidence seems conclusive that the accident of navel hem-
orrhage is not, certainly in the great majority of cases, pro-
duced under the influence of the constitutional disease with
which it seems most naturally affiliated.

When the umbilical hemorrhage has been preceded by
icterus, which gradually deepens coincidently with the repetition
of the bleeding, there is no hesitation felt in referring the acci-
dent to the acute fatty degeneration which has been considered
by Buhl as identical with the malignant icterus of adults. The

^ Report on Spont. Umbil. Hem., 1858.
' Die freiwillig. Nabelblut. Cassel, 1871.

Fatty Degeneration of New-Born 319

hemorrhage is then generally considered to be a consequence of
the icterus ; as in acute liver atrophy of adults, the blood is sup-
posed to be poisoned, "dissolved" by biliary acids absorbed from
the degenerated liver-cells, and on this account to transude
readily the walls of its containing vessels.

The autopsy in our case, however, demonstrated: ist, that
all the lesions proper to Buhl's disease may exist without the
occurrence of icterus at any time before death. And 2d, that,
in the absence of icterus, hemorrhages may occur — both umbili-
cal and visceral — and in sufficient abundance to prove fatal. It
is evident, therefore, that icterus is neither necessary to the
diagnosis of the disease, nor to the production of its most dan-
gerous symptom.

The icterus is in proportion to the degree of degeneration of
the hepatic cells. In our case, although these cells were filled
with fat-granules, their contour and nuclei were intact, none
had fallen into the detritus characteristic of the advanced stages
of acute hepatitis. We must evidently conclude that, in this
case, death occurred at a comparatively early stage of the
disease.

If the hemorrhage can be thus independent of the icterus,
the sign of blood-poisoning, there is little reason for admitting,
with Buhl, that it, or even the generalized fatty degenerations,
result from the action of a special poison in the blood. The
multiplicity of the hemorrhages indicates a cause for them that
must have been generalized throughout all the tissues and
organs of the body.

Many morbid conditions are known to be characterized by
multiple hemorrhages. Besides scurvy, hemophilia, and mal-
ignant icterus already alluded to, it is well known that in 3^el-
low fever and phosphorous poisoning, with their remarkable
analogies to the last disease, and also in pernicious anemia, which
in many respects approaches the first, visceral hemorrhages are
as frequent, or even essential to the complete evolution of the
morbid process.

It is remarkable that anatomical alterations of the walls of
blood-vessels have rarely been demonstrated in these hemor-
rhagic diseases. In scurvy, Krebel' imagines that the small
blood-vessels are partially paralyzed, a gratuitous assumption,

^ Der Scorbut, 1862, S. 190.

320 Mary Putnam Jacobi

and which would not really explain the hemorrhages. In hemo-
philia, many investigators have found no alterations of the
blood-vessels, although Legg and Grandidier admit that, in a
number of cases, their walls have been found abnormally thin.
Immerman' says: "We must accept as an anatomical sub-
stratum [of this disease], as an anomaly not exclusive to chlorosis,
a general hyperplasia of the arterial vascular system, as also the
partial fatty alteration of the walls of the blood-vessels which
usually accompanies it."

In regard to yellow fever, Haemisch- observes that, when
the red corpuscles are destroyed, the blood decomposed [under
the influence of the fever poison], the blood loses its power to
nourish tissues [including the walls of vessels] ; hence their great
fragility and consequent rupture. Ley den ^ observes that fatty
degenerations are produced by all poisons which destroy blood-
corpuscles. When the ductus choledochos was tied, and the
absorption of bile necessitated by obstruction to its passage, ic-
terus was first induced, then multiple ecchymoses. " The action
of altered blood on a part [in producing fatty degeneration] is
analogous to the effect of exclusion of blood by means of an
embolus or a ligature."

The majority of the writers on phosphorous poisoning refer
the characteristic hemorrhages directly to the alteration of the
blood, which alone is sufficient to cause transudation.'' But
Klebs^ found in the adventitia of the small vessels, both veins
and arteries, abundance of fine granules, partly albuminous,
partly fatty. There was no alteration of the vessels of the
brain, and this organ alone was exempt from hemorrhage. "The
alteration of the vessels," remarks Klebs, "is the necessary inter-
mediate lesion between the alteration of the blood and the pro-
duction of extravasation. The latter never result from coarser
ruptures of continuity of the vascular walls."

On the other hand, as is well known, Cohnheim^ has shown
that even a brief interruption to the nutrition of the walls of
blood-vessels will so injure their integrity that their pores will

» Ziemssen's Cycloped., art. Hemophilia, Bd. xii. ' Ibid., Bd. ii.

3 Der Icterus, p. i8o.

* Sec Lewin, Virch. Arch., Bd. xxi. Bernhardt, ibid., Bd. xxix. Wcgner,
ibid., Bd. xl. Baunier, Caz. Med., 1868. Lebert et Wyss, Arch. Gen., 1868,
s Virch. Arch., Bd. xxxiii. ' Ueher die Embol. Procesie, 1872.

Fatty Degeneration of New-Born 321

admit the transudation of red blood-corpuscles.' Cohnheim
has further demonstrated, that, not only interruption of the cir-
culation by ligature, but also venous stagnation will suffice to
produce the deterioration.^ Now, in the lungs of our case was
abundant evidence of extensive venous stagnation; the small
blood-vessels and the capillaries were choked with blood. The
cause of this arrest of the pulmonary circulation lay in the weak-
ened force of the partially degenerated heart. In other cases
on record, fatty degeneration of the cardiac muscles has been
much more extensive than was noted in ours; and, perhaps
correlatively, asphyxia has been a prominent symptom, while
in our case it was entirely absent. But the flagging of the heart's
action was shown even before birth, by the impossibility of dis-
covering its sounds on auscultation.

The hemorrhages in the lungs, the most extensive and re-
markable revealed by the autopsy, were therefore explicable
by one or more of several different lesions, ist. The fatty infil-
tration of the walls of the blood-vessels. 2d, Nutritive altera-
tion of these walls, not demonstrable to the microscope, and
dependent upon, (a) acute poisoning of the blood; or on (b) in-
tensely anemic impoverishment of the blood; or (c) on the
venous congestion, itself caused by failure in the contractile
force of the heart.

What is the immediate cause of the fatty degeneration of
the heart, of the blood-vessels, the epitheliums, and the gland
cells, which underlies the hemorrhage and all other clinical
symptoms of the disease?

As already noticed. Buhl assimilates the disease to malig-
nant icterus, and considers that an acute inflammation sets in
shortly before birth and rapidly fulfils its course afterwards.

For obvious reasons, the special clinical symptom of such an
inflammation, namely fever, cannot be ascertained at the time
the disease is presumed to commence. But fever has not been
noticed after birth, in the cases of infants dying from acute
fatty degeneration. To us, the facts in regard to the multiple
fatty degenerations all point, not in the direction of inflamma-

' Concerning the precise mechanism of this extravasation, and ingenious
hypotheses on the nature of the pores, see Schklarewsky, Pflug. Archiv. Bd. i.
(Ueber Diapedese.)

*Virch. Archiv., Bd. xli., S. 220.

322 Mary Putnam Jacobi

tion, but of direct arrest of nutrition, by arrest of vascular
supply.

That diminution of the quantity, as well as alteration in the
quality, of blood supplied to a tissue may induce fatty degen-
eration in it is well known. Several recent experiments set
this part in a very clear light. Zielonko' introduced two com-
plex conditions into his experiment, when he gradually nar-
rowed the entire aorta, and observed the effect on the kidneys.
According to the degree of narrowing, he found albuminous
tumefaction of the kidney, moderate hydronephrosis, and fatty
degeneration of the epithelium. But in this case the rise of
tension in the venous system must have been great enough to
account for the results, as much as the arterial anemia.

But Perl ^ imitated pathological conditions better, when he
subjected dogs to repeated venesections, at intervals of five
days. When three per cent of the body weight was abstracted
by the bleeding, fatty degeneration of the heart was always
produced.

Von Platen ^ gradually compressed the renal artery by means
of a silver clamp. This interruption to the circulation of the
kidney was followed by various degrees of fatty degeneration of
their epithelium. If only a single branch of the renal artery
was compressed, the degeneration was limited to the territory
supplied by it.

Recklinghausen'' describes a cloak {" Mantel") of fatty
infiltration around a hemorrhagic infarctus of the kidney. He
observes that, after ligature or embolus of one branch of a renal
artery, there will be necrosis in the centre of a territory supplied
by it ; but fatty infiltration on the periphery, where an imperfect
nutrition is maintained by means of collateral blood-vessels.

So far as I know. Pepper is the only writer on pernicious
anemia, who considers it as other than a primary blood-disease,
characterized by rapid diminution in the mass of the blood,
and in the number of its red corpuscles. Pepper, however, in
a single autopsy, found an alteration in the medulla of the bones,
resembling that described by Neumann in medullary leukemia;

' Virch. Arch., Bd. Ixi., S. 267.
' Virch. Arch., Bd. lix.
3 Virch. Arch., Bd. Ixxi., Heft I.
' Virch. Arch., Bd. xx., S. 205.

Fatty Degeneration of New-Born 323

and on the strength of this observation, this author ranks per-
nicious anemia as a form of leukemic disease. ^

If, for the reason alleged in the footnote, we set aside this
opinion, we should find all observers agreed in considering this
"idiopathic anemia," and the fatty degenerations characteristic
of it, as an exquisite clinical counterpart to the pathological
experiments already quoted: to the experiments of Cohnheim
and Arnold, showing the influence of denutrition of the walls
of blood-vessels upon the production of hemorrhages; to those
of Ponfick, Perl, Platen, and others, showing the influence of
diminished afflux of blood in the production of fatty degenera-
tions or infiltrations.

"The general mass of blood is diminished; there is true
oligemia; multiple hemorrhages are frequent; those into the
retina almost characteristic. We shall not err if we attribute
this development of a hemorrhagic diathesis to an alteration of
the walls of blood-vessels, caused by the alteration in the quan-
tity and the quality of the blood. Anatomical alteration of the
vessels may be demonstrated in many cases." [So in the pul-
monary vessels in our case.]

"Clinical experience teaches that the diminution of red cor-
puscles is the alteration of the blood which is most potent in
determining the [acquired] hemorrhagic diathesis." [This can-
not include hemophilia, where no such diminution exists.] "The
hemorrhages, and the fatty degenerations of the heart, the intima
of the arteries and capillaries, the hepatic cells, the renal epithe-
lium, and the peptic glands, observed in various cases of perni-
cious anemia, are explained by the diminution in the mass and
in the corpuscular richness of the blood." ^

Biermer originally maintained that the visceral hemorrhages
of pernicious anemia were always associated with fatty degen-
eration of blood-vessels. But Miiller ^ failed to find this in
quite a number of cases. "In these, other forms of nutritive
alteration of the vessels must exist."

' Am. Journ. Med. Set., Oct., 1875. This opinion seems to us unwarranted,
for in pernicious anemia, the diminution of red corpuscles is not accompanied
by a marked increase of the lymphoid elements of the blood.

^ Immermann, Deutsches Archiv, Bd. xiii., p. 217.

3 Ueber progressive Anamie. See also Gusserow, Archiv fur Gynaek., Bd.
ii., 1871. Ponfick, Berlin. Klin. Wochen., 1876.

324 Mary Putnam Jacobi

The fetus is tolerably well protected from the influence of
the poisons capable of producing "acute fatty degeneration,"
in the way Buhl and Hecker suggest.'' But, on the other hand,
it is peculiarly exposed to alterations of nutrition, caused by
variations in the amount of blood-supply. Disseminated lesions
of the placenta, not visible to macroscopic examination, may
destroy a sufficient number of villi to seriously diminish the
quantity of nutritive material brought to the fetus. To an
inflammation of the placenta, starting from the decidua, it is
well known that Rokitansky attributed many cases of "tabes-
cence of the fetus," and also most cases of "adherent placenta"
and "placenta polypus." ^ As is also well known, the possibility
of inflammation of the placenta has been denied, principally
on the ground of the very small amount of connective tissue in
it, and also on the absence of capillaries, except in the vascular
loops of the villi.

Maier, ^ however, has more recently described a lesion accept-
ed as placentitis by Schroeder '' and Spiegelberg, ^ and which
consists of a proliferation of the intervillous conjunctive tissue.
This proliferation may begin either in rudimentary conjunctive
tissue between the villi, or else in the adventitia of the arteries
as a periartritis. This proliferation causes a compression of
vessels and an atrophy of villi "which, if very extensive, must
lead to the death of the child." Or again, the process may
begin in a thickening of the decidua serotina, which becomes
closely adherent to the altered placenta tissue [apparently by
connective filaments binding together the free ends of the fetal
villi and the maternal sinuses in which they float], so that the
two can no longer be separated. From the altered serotina,
innumerable processes pass into the placenta, and there connect
with the increasingly thickening masses of conjunctive tissue.

Neunsam ^ apparently described an advanced stage of this
same lesion, under the name. Sclerosis of the Placenta. He

' Hecker relates a case of "acute yellow atrophy " in a woman seven months
pregnant, and ranks it with the acute fatty degeneration of the new-born. He
thinks that, in both cases, some sudden decomposition of the blood occurs
from causes hitherto unknown. {Monatschr. fiir Geburtskunde, 1865.)

' Lehrbuch fur Path. Anat., Bd. iii., S. 545.

3 Virch. Arch., Bd. xlv., 1869. •* Lehrbtich der Geburtskunde.

i Lehrbuch der Geburtskunde, Bd. i., 1877.

^Monatschr. der Geburtskunde, 1861, Bd. 17, p. 153.

Fatty Degeneration of New-Born 325

found, in the tissue of the latter, hard white places, showing no
trace of normal cavernous structure, and the hyaline basement
substance of the villi changed to conjunctive tissue, granular
and cloudy.^

Schroeder remarks that it is this "cirrhosis" of the placenta
which is the common cause of its adhesion to the uterus. The
chances for the life of the fetus depend upon the extent to which
the lesion progresses before birth.

It is a misfortune that, in our case, as well as in the others
like it which have been reported, the placenta was only cur-
sorily examined. But the fact that it adhered closely to the
uterine wall, and could only be detached with tearing, offers a
strong presumption that sclerosis of the placenta existed. We
may be permitted the probable hypothesis, which may easily be
tested in other cases, that by such a lesion the blood-supply to
the entire organism of the fetus was gradually diminished, as
in the experiment of applying a ligature or a clamp to the aorta
or renal artery, and that, under the influence of this oligemia,
the nutrition of the blood-vessels became fatally impaired, and
the glandular epithelium became fatty.

It is noteworthy that, in previous confinements, Mrs. H. had
also experienced an adhesion of the placenta.

' Maier insists that the lesion described by him has no connection with this,
but it is difficult to see why.

CONTRIBUTION TO SPHYGMOGRAPHY^

THE INFLUENCE OF PAIN UPON THE PULSE-TRACE

"A SUDDEN impression, however brief, made upon a sensitive
nerve, always determines, as initial effect, or slackening or a
diastolic arrest of the heart. "^

In these words M. Francois Franck sums up the results of
numerous experiments, in which the effects upon the heart,
of peripheric irritations, are delicately inscribed and analysed
by means of graphic apparatus. The trigeminus was irritated
by vapors applied to the nose, or by rapid burning of the nostril
with a red hot needle; and the laryngeal nerves, by touching the
mucous membrane of the larynx with a brush dipped in am-
monia: the auricular branches of the trigeminus, branches of the
cervical plexus, sciatic and crural nerves, were each irritated
mechanically: finally, the abdominal fibres of the sympathetic,
by pinching the peritoneum inflamed by means of previous
exposure to the air. "In all these cases, the arrest or slacken-
ing of the cardiac pulsations was observed as a constant phenom-
enon." (p. 255.) This would have passed unperceived, but for
the modification introduced in the graphic tracing of the cardiac
pulse movements.

It occurred to me that the foregoing experiment might be
exactly reproduced on the human subject, by observing the
sphygmographic tracing of the pulse at the moment that a
dentist should touch the exposed nerve of a tooth. Through
the kindness of Dr. Kidder, an opportunity was afforded to test
this suggestion. Mahomed's sphygmograph was carefully ad-

' Reprinted from the Archives of Medicine.
^ Travaux du laboratoire de M. Maroy, annfe II, 1876, p. 227.

326

Contribution of Sphygmography 327

justed to the arm of a lady, who, at the time, was suffering no
pain, but whose teeth were about to be filled.

Trace I. was taken while the upper part of the tooth was
being scraped, an operation causing comparatively little pain;

SCHAPlNt UPPER PART Or TOOTH

* LITTLE PAIN

FIG. I.

the trace is regular, and the cardiac impulse strong and well
sustained.

In Trace II, the upper line is taken before any manipulation
of the tooth. On the lower line at B, the probing begins, and
at the same moment the base line falls, to rise again, but to con-

BEfORE /WANIP.

|e6. PROBE Q

PROBE TOUCHES SENSITIVE PAI^T
FIG. 2.

tinue somewhat irregularly. At C the probe touches the sen-
sitive nerve, and instantly the line falls, the cardiac pulse is
altogether, though momentarily, arrested.

FIG. 3.

BEFORE /VflAftlP.

FIG. 4.

In Traces III and IV the same fall is also clearly seen at the
moment that the nerve is touched, (points B), but the fall is

328 Mary Putnam Jacobi

not so complete, the needle not carried entirely off the paper,
and the tracing is therefore resumed.

These traces, therefore, afford an interesting confirmation of
the law of Frangois Franck, that peripheric irritation of any
sensitive nerve, in proportion to its intensity, inhibits the action
of the cardiac ganglia. This is again a branch of the more
general law established by the experiments of Goltz,' that the
irritation of any one part of the nervous system is capable,
under certain circumstances, of inhibiting the action of various
other parts.

' Beitrdge zur Lehre von den Functionen der Nerven centren des Frosches, p. 39.

CASE OF FACIAL AND PALATINE PARALYSIS, AND

LOSS OF EQUILIBRIUM, PRODUCED BY A

FALL ON THE HEAD.^

Ralph Rosenstein, aged 2 years, was brought to the dispen-
sary of the Mt. Sinai Hospital, on October 18, 1880; the mother
stated that a week previous he had fallen off a chair to the floor,
striking the back of his head. No especial effect from the fall
was, however, observed during the two days first following the
accident, but on the third day he began to droop; he allowed his
head to fall forward, walked with a staggering gait, and finally
refused altogether to walk, or even to stand. Previous to the
fall, he was said to have walked well. Co-incident with the
symptoms, he began to cough.

On the day of examination it was found that he could stand ;
coiild move his legs while supported in a standing position, and
very freely while in bed; but would not stir from his place, even
to follow the mother who pretended to lead the way. He then
burst out crying, and sat down on the floor, but seemed unable
to try to walk. During the examination he asked for water,
and as he was drinking it was noticed that the water regurgitated
through the nose. On inquiry it appeared that this had hap-
pened ever since his fall, but the mother had not thought it worth
mentioning. No diphtheria existed or had existed to explain
this paralysis of the soft palate. The uvula was markedly
deviated towards the left. The right angle of the mouth drooped ;
thus there was evidently paralysis of lower branches of the right
facial nerve, the staphylo palatine and buccal branches. But
the upper branches were intact: the eyelids and the muscle of

' Reprinted from the Independent Practioner, Baltimore, 1881.

329

330 Mary Putnam Jacobi

the forehead presented a perfectly normal appearance. There
was no deviation of the tongue; none of the eyeball; the pupils
were unaffected. From the tender age of the child it was im-
possible to ascertain whether any deafness existed on the right
side or whether there was any sensation of vertigo. The morbid
symptoms consisted therefore in paralysis of the right facial
nerve and in loss of power to maintain equilibrium in an upright
position without paralysis of the lower extremities. The dif-
ficulty of walking seemed to be entirely due to dread of falling.

Two localities suggested themselves as the seat of a lesion
capable of explaining this group of symptoms. The first, some
portion of the petrous bone that might include at once the facial
nerve and one of the semi-circular canals of the internal ear.

It is well known at present that lesions of these canals serious-
ly interfere with maintenance of equilibrium of the body. Ex-
periments have even determined the direction in which each
canal seems to exercise an influence. Crum Brown' has so
analyzed these influences as to bring them within the same gen-
eral law as that of the co-ordinating centres in the cerebellum.
According to this law, the inclination of the body in any given
direction tends to excite the centre situated on the opposite side
of the body in such a manner that the complete falling over is
prevented by antagonism. In the labyrinthimic canals, accord-
ing to a plausible hypothesis, the nerves are stimulated when
the endolymph flows in excess into the ampullae at one extremity,
the motion of the fluid being freely determined by the position
of the head. The horizontal canals are all situated in the same
plane, but their respective ampullae are turned in different direc-
tions. When the head inclines to the right side, the endolymph
flows from the ampullae into the canal; while at the same time
on the left side it is flowing from the canal into the ampullae.
The ampullary expansion of the left auditory nerve is therefore
stimulated by the excess of pressure, and an impression con-
veyed to co-ordinating centres in the cerebellum, which tends to
restore equilibrium. Destruction of the horizontal canal on the
left side should therefore be followed by a tendency to fall to the
right, from loss of the antagonistic mechanism. According to
Goltz (quoted by Ferrier, "Functions of the brain,") division of
the auditory nerve will, in the frog, be followed by the same symp-

» Journal of Anatomy and Physiology, May, 1874.

Facial and Palatine Paralysis 331

toms as division of the semi-circular canals. This latter fact
alone could explain the circumstances of our case, supposing
that the loss of equilibrium were due to injury of the petrous
nerve. For although the aqueductus Fallopii carrying the facial
nerve passes almost between the cochlea and the semi-circular
canals above the vestibule of the inner ear, yet a lesion common
to those canals and to the facial nerve, would necessitate a
fracture of the bony floor of that aqueduct. The slight nature
of the injury sustained by the child, and the transciency of its
effects both precluded the supposition of so grave a lesion.

Again: as the lesion of the facial was certainly on the right
side, injury to the semi-circular canals, if existing at all, must
have been on the right side also. But, as already stated, injury of
the horizontal canal on the right side, is followed by a tendency
to fall on the left, on account of loss of the mechanism which
naturally compensates a tendency to fall on the left. In our
case the child always fell on the right.

This fact might at first seem to annul altogether the hypothe-
sis of the petrous bone lesion. The fact that the upper facial
remained intact might seem compatible with any form of peri-
pheric lesion, and necessitate reference to the centres. The por-
tion of the encephalon whose injury would be capable of inducing
paralysis of the right facial nerve, and loss of equilibrium, is the
inferior surface of the right lateral lobe of the cerebellum, near
the median lobe, and also near the facial nerve after its emergence
from the medulla.

"The maintenance of equilibrium is an example of adaptive,
responsive or asthetiko-kinetic action, depending on the co-
ordination in some central organ of certain afferent impressions
with special motor adjustments. The afferent factors of this
mechanism are mainly of three kinds, namely, tactile, visual,
and labyrinthic impressions. We are justified in concluding
that the cerebellum is the central organ of this co-ordination."
(Ferrier, p. 113).

According to Nothnagel {TopiscJie Him krankheiten), in co-
ordination of movements and loss of equilibrium are the only
characteristic signs of lesion of the cerebellum.^ This is shown
with special vacillation of gait, and with severe vertigo. Noth-

' Of course, as the author especially notices, this symptom is not exclusive
to the cerebellum.

332 Mary Putnam Jacobi

nagel adds, that if this symptom exist in cerebellar disease, it
indicates a direct or indirect affection of the middle lobe of the
cerebellum. According to the same authority, paresis or paraly-
sis of the facial nerve is occasionally, although rarely observed,
in lesions of the cerebellum: and is then always due to pressure
upon the nerve after its emergence from the medulla, by means
of some lesion, as a hemorrhage or tumor, sufficiently near the
surface of the cerebellum to exercise an extra cerebellar effect.
In such cases the paralysis resembles that due to lesions of the
motor tract of the cerebmm in being confined to the buccal
branches of the facial.

Such a paralysis would therefore not correspond to that ob-
served in our case, where the buccal lesion was much less prom-
inent than that of the palatine branches of the portio dura.
These branches are derived from the greater petrous nerve which
is given off from the facial at the geniculate ganglion." (Longet.)
The geniculate ganglion is situated at the first angle of the
aqueductus Fallopii, and thus lesions of the portio dura, during
their passage through this aqueduct are especially liable to be
attended by paralysis of the palate; a comparatively rare se-
quence of either completely central or completely peripheric
lesion of the nerve.

The distance is very small from the geniculate ganglion to the
internal meatus, where the auditory nerve still lies side by side
with the facial. It is conceivable that a slight hemorrhage
should occupy all this space, and thus co-incidently affect the
auditory nerve, the facial, and the branches emanating from its
geniculate ganglion.

The experiments of Goltz, already quoted, which, showing
that section of the auditory nerve may have the same effect as
lesion of the semi-circular canals, would explain why a lesion in
the vicinity thus defined should occasion loss of equilibrium.
The auditory nerve, though it represents neither the organ
receiving labyrinthic impressions nor the central organ receiving
them, unquestionably constitutes the path by which they are
conveyed to that central organ, the cerebellum. A portion of
the roots of the auditory nerve pass to the cerebellum in the
restiform bodies, (Meyner) so that each auditory nerve is con-
nected with the lateral hemisphere on the same side.

According to Ferrier, experimental lesions of the lateral lobes

Facial and Palatine Paralysis 333

of the cerebellum, whether destructive or irritative, are followed
by the same results as are lesions of the peduncles. The dis-
placement of the body is sometimes toward the side of the lesions,
sometimes toward the opposite side. The latter, observes
Ferrier, is more likely to occur when the lesion is limited, the
former when it is extensive.

Hitzig, (Untersuch iiher das Gehirn, p. 203) pointed out that
the passage of a galvanic current through the cranium was fol-
lowed by a sudden sinking of the head towards the side on which
the irritation is applied, i. e., where the anode is placed. Now
an irritation transmitted to the lateral lobe of the cerebellum,
along the auditory nerve, should have the same effect as this
electrical irritation. Equilibrium would be disturbed from the
unequal stimulus of the co-ordinating centres, and, as experi-
ment shows, without clearly explaining why, the tendency might
be to fall on the same side as the lesion. The case differs from
that of lesion of the labyrinthic canals, affecting the terminal
expansion of the nerve, because that implies destruction of a
mechanism by which a tendency to fall towards the other side is
habitually compensated, whereas, lesion of the trunk of the nerve
coincides in effect with lesion of the lateral lobe of the cerebellum
on the same side.

From the foregoing reasons we have ventured to diagnose a
hemorrhage, extending from the internal meatus through the
aqueductus Fallopii as far as the geniculate ganglion, as the
cause of the symptoms observed in the case of Ralph Rosenstein.

INAUGURAL ADDRESS AT THE OPENING OF THE

WOMAN'S MEDICAL COLLEGE OF THE NEW

YORK INFIRMARY, OCTOBER i, 1880/

Ladies — It is a good plan, on the threshold of any important
enterprise, to pause and take a survey of the field we propose to
traverse ; otherwise we may lose our way, and arrive at the wrong
goal at last.

Every enterprise involves difficulties. Difficulties are in-
separable from any condition of existence. The question there-
fore always is, not "Are there any difficulties to encounter?" but
"For precisely what difficulties must I prepare?" The difficul-
ties involved in the study and practice of medicine are intrinsic
and extrinsic; and we will consider each in its order.

In addition it will be profitable to inquire what especial dif-
ficulties attend the study of medicine by women ; and, finally, to
point out some which we have practically encountered in the
working of this school.

The first intrinsic difficulty in medicine consists in the great
mass of facts which it is necessary to know, and in the variety
of sciences which must be understood in order to interpret these
facts. There is a general impression among non-medical people
that all medicine can be learned simply by listening to what sick
people have to say for themselves ; that any one who has listened
during a few months or years to such conversations knows all
about medicine — is rich in experience; that what such an one
does not know is not worth knowing. Now, in reality, such a
method would not suffice to teach the pathology of a cold in the
head, although a thousand sufferers related the details of their

* Reprinted from The Chicago Medical Journal and Examiner, 1881.

334

Inaugural Address 335

illness with the utmost loquacity. At the very outset of clinical
study it is well to be impressed with this fact : namely, that what
the patient has to tell you constitutes precisely the least impor-
tant part of what you must learn about him in order to be able
to understand his case, and to do him any good. This is not
only true in regard to children, to insane people, to those who are
for the time delirious or unconscious, or to those whose willful
exaggerations or reticences evidently distort the description of
their symptoms. It is true of every one who does not understand
the pathological significance of one symptom as compared with
that of another : true, therefore, of every one who is not himself
a physician. Let us take an individual case — it makes scarcely
any difference what. As serving to illustrate many points, I will
select a case of fractured skull. The physician is siunmoned in
haste, and learns that an hour previously the patient had fallen
from a scaffolding to the street; had been picked up unconscious,
and brought home in the same state; that shortly after reaching
home he had vomited, but had not, as the saying is, yet come to
himself. The physician finds the patient in bed, motionless and
insensible. His eyes are closed, but if the lids be raised the pupils
will be found to contract, perhaps sluggishly, to the light, and the
lids quiver more or less if the conjunctiva is tickled. The breath-
ing is slow and rather labored, and at each respiration the cheeks
puff out as if the man were forcibly smoking a pipe. Perhaps
from time to time one of the arms is raised and moved con-
vulsively backwards and forwards, then falls again. The face
is pale, but when the doctor lays his finger on the pulse he finds
no sign of exhaustion ; the pulse is full and hard, and rather slow.
He will notice that the clothes are wet with urine. In examining
the head he finds on one side, near the vertex, that the hair is
matted; and, separating the mass, he comes upon some clotted
blood. He presses his finger in the center of the clot, and may
find a depression below the level of the cranium. Perhaps
when he presses on this depressed portion the convulsive motion
of the arm will re-commence. On searching farther, he may
notice a clear fluid running from the ear, on the same side with
the visible fracture. Here is his case. Now, for the sake of sim-
plicity, I have so stated it that, in regard to the main fact, the
doctor is not called upon to make any diagnosis. There is no
doubt about it; the man has fallen and fractured his skull. But,

336 Mary Putnam Jacobi

before the physician can understand either the extent or the con-
sequence of this injury, he must be extremely familiar with the
anatomy of the injured region. He cannot learn this anatomy
from looking at the patient, nor at a hundred similar patients.
He must have had the opportunity on many dead ones to dis-
sect out all the parts, and study repeatedly their relations to
each other. Then only could he know, in the first place, even
that there was a brain inside the skull ! Further, that the piece
of bone which had been driven in by the blow had probably torn
the membranes covering the brain, and even the pulpy substance
of this vital organ itself. He must remember the sinuses in the
membranes, and the effusion of blood that poured out from
them was probably now pressing on the surface of the brain.
He must be able to tell, in order to furnish the basis for his
physiological analysis of the case, just what part of the surface
had been injured — the part whose irritation is known to cause
convulsive movements of the right arm. He must be able, from
his previous knowledge, to trace downwards the direction of an
invisible crack, leading from the visible fracture to the base of
the skull, and splitting another portion in such a way as to allow
of the escape of the clear liquid from the ear. All this knowledge,
and that of other details which I omit, must the physician bring
to the case from the study of the first science on which medicine
reposes — the science of anatomy. He then begins to trace the
relation between the symptoms he has observed and the lesion
he has discovered, by means of his knowledge of the functions of
the parts involved — in other words, by his knowledge of phy-
siology. By a violent shock the functions of important organs
have been rudely interrupted. The physician who was not
already well acquainted with these functions would be entirely
unable to explain why a blow on the head should suspend or
alter them. He could not even see any reason for the suspension
of consciousness, of feeling, of power of movement, which has
been induced by this blow. Still less could he understand the
vomiting, the involuntary emission of urine, the convulsive
movements of the arm, the puffing of the cheeks, the changes in
the respiration and the pulse. In other words, unless he had an
intimate acquaintance with the working of the machinery of the
body while in order, he would be as little able to understand its
disorder as a bricklayer to know why a watch had stopped, or a

Inaugural Address 337

shoeblack to mend a locomotive. But the analysis of the case
is not finished. The fall of a living body from a height is an
event not contemplated in the physiological workings of the
organism. It is effected according to physical laws, and the
fracture of the skull takes place in the same way, and with the
same modifications as would a fracture of any inorganic elastic
globe. The radiation of the fracture, the effect of the rebound
of the head from the pavement, and of the brain within the skull,
cannot be studied by the aid of anatomy or of physiology alone ;
a third science must be invoked — that of physics. Nor is this
all. I have spoken of the clear fluid running from the patient's
ear. To the uninitiated this would seem to be of much less
importance than the blood which matted his hair. But the
physician sees in it a symptom of very serious import ; he knows
that it is a sign of the fracture of a certain portion of the base
of the skull, and foretells almost certain death. So much he
knows, or should know, as a fact of clinical experience — that is,
of the clinical experience of other people ; for he ought to be able
to interpret this symptom as perfectly in the first case he ever
saw as in the fiftieth. To understand exactly what this clear
fluid is, he must, however, interrogate something else than
clinical experience, for that has interpreted the matter in several
different ways. The question has been solved by clinical analysis
of the fluid, which has shown that it does not resemble the serum
of the blood, which at one time it was supposed to be, but the
so-called cerebro-spinal fluid, which bathes the brain and spinal
cord, and which cannot be removed, in even small quantities,
without the greatest risk to these vital organs. The gravest
feature in a case of fracture of the skull is interpreted by means
of the science of chemistry.

Here, then, are four separate sciences, with entirely distinct
methods, with which the physician must be to a considerable
extent acquainted before he can in the least understand the
condition of the patient in the case we have imagined : anatomy,
or the science describing the form and relative situation of organs ;
physiology, or the science of the functions of these organs;
physics, or the science of the movements of masses; chemistry,
or the science of the composition of bodies, including the solids
and fluids of the animal organism. When all these have been
applied to the problem, the physician is still at the outset of his

338 Mary Putnam Jacobi

investigation. It is not enough that he sees, or even correctly
understands, the condition in which the patient is; he must be
able to foretell the series of changes which this condition is
likely to undergo, during its progress towards death or recovery.
To do this he must be acquainted with a fifth science — pathology;
a science laboriously elaborated from all the experience, the
observations, the clinical and post-mortem analyses which
have been accumulated during the historical period of the race.
Morbid anatomy is properly a branch of pathology, and nothing
can be more absurd than the idea that the clinician can busy
himself with the sick person during life, and leave to a specialist
in "pathological anatomy" the examination of diseased organs
after death. You can only properly observe the living sick man
when you are able, in imagination, to pierce through the outer
coverings of his body, and watch, step by step, the morbid pro-
cesses which are creeping onward in the recesses of the organism.
For this purpose it is essential that a science, really a branch of
anatomy, but often regarded as distinct, be assiduously cultivat-
ed. I mean the science of histology. It is only when the
microscopic structure of the fractured bones and torn mem-
branes is perfectly known that the physician can understand
many of the minuter morbid processes whose possibility he
foresees — as an osteomyelitis, a meningitis, a capillary apoplexy.
Knowing what exists, and also what is likely to occur, the physi-
cian is now prepared to intervene to help the patient, and to
avert danger as far as this may be possible. In other words,
having applied the arts of diagnosis and prognosis, in accordance
with the laws of pathology, he is able to apply the art of thera-
peutics according to the indications furnished, on the one hand
by surgery, on the other by the science of the properties of drugs.
He will lift up the depressed fragment of bone by means of a
trepan; he will apply ice to the head, to keep down hypersemia
of the meninges; he may possibly give bromide of potassium to
deaden the activity of the brain when consciousness returns
and delirium is imminent.

From this single illustration, you may at once learn several
peculiarities of the physician's work. In the first place you have
noticed that the knowledge required is not merely considerable
in amount but various in kind, and that all these varieties must
be co-ordinated into a single conception, which we may entitle

Inaugural Address 339

knowledge of the condition of the patient. In every step of the
physician's career he is obUged to perform this work of co-ordina-
tion; obHged not only to know in detail, but to generalize and
combine.

Now the capacity for systematic mental combination is essen-
tially a cultured capacity, and a capacity whose effective attain-
ment is a matter of a great deal of difficulty. It is sometimes
proposed to evade this difficulty by dividing up medicine into a
great number of small sections or specialties, and encouraging
every one to devote himself to only one. Even were this done,
the difficulty in question would not be removed, but only pushed
back a little. Even when a physician professes to attend only to
the diseases of a single organ, he still has to do not with one dis-
ease but with an entire class of diseases. To decide whether one
of his diseases exists, he must know enough about a good many
others to be able to exclude them from the diagnosis. Or, if he
cannot do this, he must get some one else to make the diagnosis
for him — that is, to take out of his hands the first large part of
his own work. If we suppose these preliminary questions all
decided, — and no doubt to remain that disease exists in the organ
appropriated by this particular specialist — we still can only
understand this by means of a mass of anatomical, physiological
and clinical details, out of which he must build up the general
conception of the case. Thus the mental operation is the same
in kind for the specialist as for the general practitioner.

Specialists are needed for original researches, and to develop
the field of medicine in such a way that it may afterward be
cultivated by the general practitioner. Auscultation was once a
specialty, and only a few physicians even pretended to know how
to use the stethoscope. But today, as you are aware, scarcely
any one claiming the name of physician would dare to disclaim
his ability to do so.

It will always be desirable moreover, that certain persons
endeavor to acquire unusual skill in some particular directions,
that they may be called upon occasionally to decide in questions
of unusual difficulty. But it must be left to the general practi-
tioner to call in the specialist, as the judge calls an expert into
court, to assist in making up the decision. The responsibility of
the decision must always rest with the judge, or the physician, —
after they have heard all that the experts have to say, and con-

340 Mary Putnam Jacobi

trolled their report by means of their own knowledge of the
subject, and general relations of its parts to each other.

There is another way in which a specialist may be called in:
namely, like a chiropodist to attend to some entirely subordinate
and presumably insignificant detail. Whoever adopts a specialty
for the sake of narrowing his knowledge, and not in order to
deepen it, is liable to become a speciaHst of this kind — a mere
corn doctor; with no valid claim to membership in a liberal pro-
fession.

We return therefore to our assertion that it is impossible for a
real physician to escape the necessity of constantly dealing with
multiple groups of facts. He cannot therefore be dispensed from
the necessity of acquiring the mental culture which alone can
enable him to accomplish this task. To further illustrate my
meaning, I would point out that there are four successive degrees
of generalization that may or must be effected by the physician.
The first degree is that which I have already shown to be involved
in the very simplest diagnosis of disease in a single organ of the
body. In a second degree of complexity the physician is obliged
to consider also the co-existence of a morbid condition in some
organ, and to ascertain which, if any, are the relations between
these two. Thus, if the same patient be suffering from dyspepsia
and endometritis, it is very important to know whether the dys-
peptic symptoms result from the irritation of the endometritis,
or whether the endometritis is the final expression of a state of
denutrition originated by the dyspepsia. If, again, a pregnancy
complicates the uterine disease, the question of treatment is ren-
dered more difficult by the risks of interfering with the pregnancy.

In a third degree of generalization, the physician must rise
to considerations of the pathogeny of disease, and these are
inseparable from general philosophic notions to enable him to
grasp the theory of the matter. Thus, in investigating a case of
phthisis, the physician will go but a little way who rests with the
report of subcrepitant rales at the apex of one of the lungs. It is
imperative that he understand the theory of phthisis, and the
relations between the theory of Bayle and Laennec, which would
attribute these rales to ruptured tubercle; the theory of Rind-
fleisch, which would explain them by the breaking down of
masses of tissue chronically inflamed; the theory of Buhl, ex-
plaining the ulceration process by a diphtheritic-like infiltration.

Inaugural Address 341

Immediately or remotely, the practical treatment of phthisis is
moulded by the theory which may have been adopted.

Similarly, the practical treatment of uterine diseases must
vary considerably when the theory of menstruation regards this
process as a congestion, or as a plastic process of growth.

The highest degree of generalization is that involved in the
pursuit of original researches. Upon this we will not now stop
to speak.

Now, as I have already said, the capacity for generalizing
is essentially a cultured, an acquired capacity. Whenever it
seems to be natural, that is, to come without any special training,
it is always wrong. That is to say, untrained persons of active
minds, and who are often very ready to generalize, invariably do
so from too small a number of facts or data. Hence their con-
clusions are inadequate or absurd. Homoeopathy furnishes an
excellent illustration of just this kind of generalization. It has
picked up a superficial resemblance between things; has refused
to analyze further the real relations of these things, and then
insists upon having discovered the true theory of their relations.
Thus Hahnemann gives as an illustration of the way in which
natural instinct appeals to the law of Similia : the case of a cook
who, having burned her finger, plunges it into warm water; or,
the boy whose fingers are frost-bitten, yet who takes care to rub
them with snow. Now this accidental resemblance between the
cause of the injury and the treatment explains nothing. A little
deeper examination shows that, in the first case, the warm water
is required to relax the distended blood vessels; in the second,
the cold is needed to restore the circulation gradually and not
with a rush, which might prove fatal to the tissues. In these
celebrated examples, an immense fallacy is accepted, by omission
of the philosophical distinction between two kinds of causes:
the efficient cause, the burn, which has initiated a train of morbid
processes; and the proximate cause, that is, the anatomical and
physiological conditions upon which the symptoms immediately
depend.

To train the mind to handle large masses of facts, it must be
gradually accustomed to work with somewhat smaller masses of
more accessible facts. This is the reason for that general liter-
ary education which, in all European schools, is exacted as
an indispensable preliminary to medical study, and which,

342 Mary Putnam Jacobi

in this country, is often considered as superfluous. But it
can only be so considered by those who have never tried to
analyze the mental operations involved in the simplest medical
work.

Our illustrative case shows that something else is necessary
also. The senses must be trained as well as the mind. I will
not now dwell upon the methods for training the senses, but only
point out two facts. First, that the facility and accuracy with
which the senses work, is largely in proportion to the amount of
mental training that guides their operation. You can see, hear
and feel a hundred fold more when you know before hand exactly
what is to be felt, or heard, or seen; and when you have an ideal
standard with which you can compare the results furnished by
your eye, ear, or finger. In the second place, it is logical and
much easier to train the senses by means of simple exercises
before attempting more complex ones. Thus an excellent pre-
paration for learning how to observe in anatomy, is to pursue
observations in botany.

It is now worth while to inquire, since the study of medicine
is so vast, what proportion of it can possibly be mastered during
a given term of years: in other words, what we may expect a
student to know who presents himself for graduation. As the
foundation of everything, a really complete knowledge of ana-
tomy is indispensable. It will not do to know that an artery is,
as the boy said of Abraham, "there or thereabouts." It will not
do to have a general idea that the nerve centers are divisible into
a cerebrum or cerebellum, medulla and spinal cord. The ana-
tomical knowledge that is not precise and accurate is as unavail-
able for the physician as would be a general idea of the county
in which a person lived, to the postman charged to deliver a
letter to him.

There is another reason for demanding completeness of know-
ledge in regard to coarse and fine anatomy, and that is, that it is
so readily forgotten in after practical life, and requires to be so
constantly revived by fresh reference as wanted. Students are
apt to think that therefore it never need be fully known at any
time. This is a great mistake. What has once been firmly
stamped upon the mind, can easily be revived; what has always
been vague, will always remain so, unless there take place such a
radical change in mental habits and methods as we have no great

Inaugural Address 343

reason to expect. The science of chemistry, so far as regards its
relations to medicine, should also be perfectly known at the out-
set, and can be known because these medical relations of chemis-
try are at present comparatively so few. Physiology, on the
other hand, embraces a much wider field — more indefinite and
more complex details. The knowledge acquired of it during a
medical curriculum, must be small as compared with the relative
amount attainable in anatomy and medical chemistry. But
absolutely, this amount is considerable. It is of the greatest
importance that the student learn to distinguish the different
degrees of certainty which exist between the various physiological
doctrines he hears enunciated. It is in studying them that he is
first introduced to the peculiar difficulties of the study of medi-
cine, inherent in its imperfection, in its complexity, and in its
progressive character. It is impossible to study physiology by
the memory alone. Even to remember its details requires a
habit of mental poise — a capacity for criticism and judgment
which is only acquired by very careful training. In testing the
candidate therefore, we expect to find, not a complete knowledge
of physiology, but an accurate knowledge of certain fundamental
facts, familiarity with accepted methods for both the acquisition
and application of physiological knowledge, and some trained
judgment in regard to the grouping of facts known ; finally, sound
and vivid perceptions of the relations of physiology to medicine,
and of their constant interdependence upon one another.

Coming now to medicine proper — what may we expect a grad-
uating student to know ? It is a mass of knowledge so vast (often
so confused), so unsystematically grouped together — so largely
empirical, — so unequal in its development; its acquisition de-
pends so much upon prolonged clinical experience with personal
responsibility, that it is really very difficult to define just how
much may be acquired; how much and what must be expected
of any one after a given course of study. We can, however, say
this: First — That the graduate must be thoroughly acquainted
with the rules of diagnosis, and show his ability to apply them in
any given case. Second — That he must be acquainted with the
typical outline of all classical diseases, and thus know the symp-
toms upon which the diagnosis is based. Then there will be
nothing to prevent him from diagnosticating even the very first
case he ever sees of even the rarest disease. Whoever is able to

344 Mary Putnam Jacobi

do this; whoever has reached a standpoint from which he can
scan the entire horizon of medicine, has reached a beginning
whence nothing need prevent indefinite progress. But unless
this beginning be reached, the physician is really incapable of
making the first decision about any one who comes to his office,
or who calls him to their bedside. A doctor who did not know
that coryza was one of the symptoms of syphilis, could not safely
pronounce with positiveness upon the nature of an apparent
cold in the head. Another, who knew of no eruptive fever but
measles, would certainly be incompetent to decide that the rash
in a given case were not scarlatina or small-pox. No young
physician can be expected to know all about all diseases ; but he
must be acquainted with at least the existence of all that there is
to know about. And he must, moreover, have attained sufficient
mental breadth and grasp to be able to keep the recollection of
all firmly and clearly before his mind at the same time. Now
this knowledge is really quite attainable by a curriculum of three
or four years' duration, if the study be sytematically and intelligi-
bly pursued.

The art of therapeutics is much more difficult of acquisition.
The treatment of a disease involves many more considerations
than even does its diagnosis; and these are susceptible of much
greater variety in grouping. Surgical therapeutics, or, as you
would perhaps call it, operative surgery, is much the simplest,
and, accordingly, is much farther advanced. The logical method
would prescribe that before studying the effect of drugs inter-
nally administered, the pupil should be carefully trained to
watch the effect of the topical applications, the various manoeuv-
ers and operations, by which a surgeon deals with cases of external
pathology. The question that meets us at the outset is, Is it
really possible for us to produce any definite effect upon the pro-
cesses of a living organism? This question is at present better
answered in surgery than in the domain of internal medicine;
and we should therefore seek for the answer first there. Yet so
easily are we deluded into believing that whatever is familiar is
simple, and whatever is unfamiliar is abstruse, that I suppose
there is not one of you who would not believe that the action of
a dose of castor oil was much easier to understand than the action
of a fracture splint; or, again, that any woman physician might
be expected, in virtue of her sex, to know something of pessaries,

Inaugural Address 345

but need not be expected to know anything of orthopoedics,
although a pessary for the replacement of a dislocated uterus is
strictly a surgical and, by analogy, at least, an orthopoedic appar-
atus. What we may expect of a student at graduation is, to
know the precise physiological action of drugs so far as this is
known at present ; to know the principal variations in such action
occasioned by disease; to know the principal indications for the
use of the drugs ; and, finally, the principal diseases in the course
of which these indications present themselves. It is unnecessary
to add that he must know the doses and preparations of these
same medicines.

To apply my previous test, I would say that the theoretical
possession of this amount of knowledge is quite attainable in
three or four years. The practical availability of it, is attainable
with such slowness and difficulty, that it would really be desirable
to pass a law forbidding any young physician from assuming the
full responsibility of prescribing until, for a year, privately or in
hospitals, he had practiced under the close supervision of some
one else.

The work of co-ordinating multiple facts, which I have said
was the characteristic work of the physician, must be begun by
the student in his most elementary attempts at mastering knowl-
edge. This is the only way in which he can remember the
immense amount of facts he is expected to know. He must bind
them firmly into a single bundle, or a definite number of single
bundles, or they will all fall apart like scattered sticks.

Every time you learn anything new, you should stop and ask
yourselves whether you know everything which is implied in that
knowledge. In studying the anatomy of muscles, you have an
opportunity of reviving your knowledge of the bones on which
they are inserted. In studying the course of arteries and the
distribution of nerves you refresh your recollection of the muscles
which serve as landmarks to them. In observing any case of
disease in the college clinics, it should be your self-imposed duty
to ask yourselves if you know all about the anatomy, histology,
and physiology of the organs involved in the disease. The con-
stant, faithful, patient repetition of these inquiries would contin-
ually render the co-ordination of your various studies more and
more easy to you ; would train you in the capacity, invaluable in
a physician, of bringing to bear all your knowledge at any given

346 Mary Putnam Jacobi

point, and of turning it to account wherever it was wanted. For
here is the immense peculiarity of medical knowledge — it must
all be turned to account. It is tremendously, often terrifically,
responsible. It is this sense of responsibility which should be
constantly impelling the medical student to a determination to
grasp a subject, instead of remaining content to wabble about in
it. Medical knowledge is not something which can be purchased
and applied to a patient like a plaster or a poultice ; it is some-
thing to be handled — like a tool, like an ax — and the effective-
ness of the handling depends upon the firmness of grip of him
who holds the instrument. This fact involves a double responsi-
bility on the part of the teacher. It is not sufficient to expound
doctrines and convey information; it is essential to train the
minds of the persons who are expected to profit by it. This
requires systematic intellectual gymnastics; requires repeated
practice in all the mental operations which, in after life, the stu-
dent will ever be called upon to perform. Thus he must be
taught, he must probably be compelled, not only to remember ap-
proximately, but accurately; not only to be able to think when
at leisure and unencumbered, but under strong pressure, and
perhaps in the midst of the most embarrassing circumstances;
to express himself, not only in a slovenly, awkward, halting man-
ner, calculated to make nervous people impatient, and timid
people alarmed, and arrogant people contemptuous, but in such
a clear, concise, forcible way as shall always compel attention
and extort respect from the very midst of hostile criticism. The
physician, like the soldier, must be trained to act under fire; and
a training for mere holiday manoeuvers, out of sight of the enemy,
is lamentably insufficient for the purpose. Human minds are
not pint-pots, into which we may pour water or milk or wine at
our option; nor are they often Danaides, which may be quickened
simply by immersion in a golden rain from heaven. They are
living organisms which can only use what they have assimilated
and digested, and wrought into the texture of their inmost
fibers.

This vigorous assimilation demands qualities of grit, which
are as much moral as intellectual. Many moral qualities are
needed in the practice of medicine to meet the difficulties which,
though extrinsic to the case considered as an intellectual problem,
are very important in its practical discussion. The fundamental

Inaugural Address 347

difficulty of all lies in the fact that so much depends not only on
rigid adherence to rules (and there are many more rules for guid-
ance than you might sometimes suppose), but that nevertheless
the final arrangement must be left to the individual tact, discre-
tion, and judgment of the practitioner. The theoretical and
practical are inextricably intertwined; and the promptness with
which theories will often be found to effect modifications of prac-
tice, in itself renders medicine one of the most interesting spheres
of human existence. Hence in the most abstract reasoning — ^if
the physician be capable of such — he must always keep his mind
intently focussed upon the practical purpose towards which it
must converge. He must see all his reasons, not hovering about
in the air, liKe bodiless cherubs, around the bed of his patient;
but embodied in tangible facts and definite actions. He must
see that his antiseptic fluids actually reach the infected surfaces ;
he must see that his hot baths are of a given temperature, and
that his cold applications are renewed as often as they grow
warm; he must know whether the medicine prescribed has been
vomited, whether the food has been given at the stated intervals,
whether the pulse has responded to the stimulant. He must
know how to enforce his directions, in spite of the reluctance, or
indifference, or carelessness, or stupidity, or forgetfulness of his
patients; in spite, moreover, of the interference of friends, who
invariably try to persuade the sick person to call in another
doctor. In many cases the physician must almost, as it were,
carry his patient in his arms, encouraging, urging, consoling,
inspiring him. To do this he must be capable of sympathy with
physical suffering, at once delicate and profound. To be effica-
cious, this sympathy must be fine, and not blubbering; it must
feel for the patient ten times, a hundred times as much as it
audibly expresses for him; it must manifest itself in deeds, not
in words; in indefatigable efforts to accomplish the essential, not
in rambHng talk about irrelevant trifles, even when, to the sick
person, these seem to be the most important.

And at the same time, while treating his patient as though he
were a personal friend — while, if necessary, risking his life for
him — the physician must never forget that this same patient is,
from the nature of things, a possible enemy. A physician pre-
scribes somewhat as the Spartans under Lycurgus were permitted
to propose a new law. If the proposition succeeded, the innova-

348 Mary Putnam Jacobi

tor was honored immensely; but if it failed he was put to death.
By the most scrupulous honor and the most conscientious care,
the physician is bound to justify a claim to the absolute confi-
dence of his patients; but he must never give them his. He must
never be off his guard ; never forget that he is the object of inces-
sant criticism, not only for what he does, but also for what he
does not do, and for every detail of his way of doing. It is essen-
tial that in every detail, in every expression, in the entire mental
atmosphere of the physician, the patient should feel himself in
the presence of a superior person. He must be conscious that a
mind warm, vivid, and penetrating is dealing with his case. He
must be conscious, also, that notwithstanding this personal sym-
pathy, the physician is studying his case as coolly, impartially,
abstractly, as if it were a problem in algebra. If he does not do
so — if, moreover, he fail to solve the problem — sooner or later the
patient will leave him, perhaps with the best good wishes, but
still he will leave him, and try his fortune elsewhere.

You see, therefore, that, in order to be a physician, it is not
sufficient to have a good memory and be able to pass examina-
tions. This is indispensable, but much more is required. The
capacity to examine minutely, yet generalize comprehensively;
to take large views, yet not overlook the smallest details; to be
quick to notice, yet slow to speak ; to reason cautiously, yet decide
promptly; to be at once very cool and very warm; to be tena-
cious of one's reputation, yet indifferent to careless opinions; to
be sensitive, yet not touchy ; to be patient in temper, yet capable
of wrath; to be absolutely honest, yet successfully prudent; to
be unworldly, yet capable of managing the forces of the world —
all these mental and moral capacities are necessary to enable a
physician to study practical medicine, to practice medicine, and
to build up a practice out of services rendered to a crowd of suf-
ferers, at once helpless, ignorant, exacting, and capricious.
Varied as are the mental and moral capacities required for this
enterprise, they may be all traced back to three, namely : Ability
to think, character to control, and honor to act from an internal
instead of an external standard of obligation. When these
qualities are not possessed, or have been insufficiently developed,
one of two things happens. Either, in the competitive struggle,
the ill-prepared physician gets crowded out by more capable
rivals; or else, he manages to hold his place, but at the expense

Inaugural Address 349

of patients, ill-treated by him, and who might have been better
treated by some one else.

These patients are the persons who must be kept in view by
the examining boards, who are licensed with the power to grant
medical diplomas. This power constitutes a tremendous social
responsibility. It is quite possible for a medical college to have
no other function than that of testing candidates. This is the
case with the University of London. It gives no instruction at
all, but it grants degrees to all persons, who, having been edu-
cated elsewhere, are able to pass the scrutiny of its examiners.
It must always be the principal function of a medical college to
fix the standard of attainment ; — and to point out what must be
learned and what must be done to reach this: and thus, finally,
ascertain as far as possible whether candidates have fulfilled these
conditions. The college is then able to turn to society and say
to people entirely helpless to judge for themselves: "Here is a
person to whom, in perfect confidence, you may entrust your
most important interests. Upon his knowledge, his skill and
judgment you may rely as completely as upon that of any one of
equal professional age in the profession ; and upon his honor, you
may at once rely absolutely." The responsibility attaching to
this assertion is so tremendous : the consequences of a false assur-
ance of confidence may be so various and so disastrous, that in
comparison with it, sympathy for the disappointment of an un-
prepared candidate ought to be left entirely out of sight. The
examining board betrays its social trust the first moment that it
consents to confer a certificate of capacity upon an incapable
person. In such a case, it becomes culpable of the same crime,
for which, after the recent Seewanhaka disaster, the grand jury
indicted the inspectors to whose false assurances of security that
terrible disaster was traced.

This consideration comes up with especial force in regard to
women medical students. These are still, by the majority of the
public, regarded as disqualified from the practice of medicine
merely by reason of their sex. The same reason is not always
given. It is sometimes alleged that they have too little mental
capacity; sometimes too little general education; sometimes too
Uttle physical health; sometimes that their judgment is too
flighty ; sometimes that their temperament is too excitable ; some-
times that they have too Uttle self-reliance; sometimes that they

350 Mary Putnam Jacobi

have too much self-assurance. But that, whatever be the reason,
they are intrinsically unable to make, or to be made into, safe
practitioners.

When you have assembled together in an institution legally
chartered and recognized by the State for instruction in medicine ;
when you find yourselves going through the same exercises as
those which are being carried on in every other college in the city :
ultimately brought to a commencement hall, where a band of
music and a valedictory address seem to imitate to perfection
those of the best equipped universities, it is not unnatural for you
to feel as if all this vexed question about women's capacity for the
profession of medicine had been entirely settled. In reality,
however, it is not so. It has almost reached the point where it
can be decided on its real merits, and on the actual results of the
work done by women as physicians. But it has not quite reached
even this point, since the preparation afforded to the mass of
women students is still inferior to that which is attainable, if not
attained by men. In the meantime, although skepticism has
become more polite, or veiled, it is still much more wide spread
than you would probably imagine. Only a few months ago a
prominent physician of this city expressed the doubt, — in private
conversation it is true, — whether, in twenty-five years from now,
any women would be found practicing medicine. A professor
of Ann Arbor has recently written two letters to a Michigan
paper to express himself as "decidedly adverse" to the attempt
of women to practice medicine. A few years ago, one of the
lady trustees of this college told me that a friend of hers asked
her why she had anything to do with women doctors, when it
was notorious that they were all Free Lovers. Last year another
lady trustee explained the indifference of so many influential
people to the success of this school, as compared with their
interest in the Training School for Nurses, on the ground that the
latter were felt to be a necessity, while a medical school for
women could only add a poorer class of doctors to an already
over-crowded profession. There were more doctors turned out
now every year than could find work to do in the community;
there was not really any reason for helping to manufacture more.
When I suggested that some of the women doctors were expected
to displace a certain number of men, she was perfectly astonished.
She tacitly took for granted that all the men must first find some-

Inaugural Address 351

thing to do: what was left over only, could be taken up by the
women.

But now this is the very point at issue. Since society is,
numerically speaking, already supplied with quite enough doc-
tors, the only way in which women physicians can possibly gain
any footing is by displacing a certain number of men. In order
to do so, they must evidently show qualifications superior to
those of the physicians whom they displace, and sensibly equal
to those of the physicians with whom they are to be ranked on an
equality.

Now, it is well to at once recognize the fact that a good many
difficulties stand in the way of both achievements, and these can
only be surmounted when they have been distinctly recognized
and systematically provided for.

It is very difficult for women to make headway against the
settled opinion of society that they are unfit for final responsi-
bilities. This opinion not only often hinders their education to
responsibilities, by preventing people from entrusting them into
their hands; but it reacts upon their own minds, is liable to make
them hesitating, undecided, timid, and thus still more to justify
the social prejudice. It is a common remark, "Women do not
feel any confidence in women; in an emergency, they must always
appeal to men." This, because it is the habit of centuries so to
appeal; because the mass of knowledge, power, and force is still
overwhelmingly on the masculine side; because, perhaps, the
mass of such force always will be so distributed, and the women
in positions of first-class responsibility will always be sufficiently
in the minority to be deprived of the benefit of traditional influ-
ence and prestige. The claim to equal confidence as made by a
woman must be a peculiarly intellectual one, because it must be
sustained in spite of a conspicuous inferiority of physical strength.
To produce upon the mind of the average public the same im-
pression as may be made by a masculine physician, the woman
must exhibit comparatively more force of mind and character,
because the force of body is so much less, and in a question of
forces the impression unconsciously received from physical size
must be taken largely into account. It is like a watch as com-
pared with a locomotive; if there be not greater precision of
action in the one, to balance the imposing massiveness of the
other, the more delicate instrument must be crushed with con-

352 Mary Putnam Jacobi

tempt. Many mental habits of women stand in the way of their
acquiring this superior precision and surety. These can only be
acquired by means of repeated tests, and by the prompt rejec-
tion of all work which does not come up to a given standard.
But women, as a class, are never habituated to test their work;
and have an almost irresistible tendency to appeal to some per-
sonal influence to avert the consequences of its failure. I do not
wish to make any protest against the habit of appeal to personal
influence; it is ingrained in the nature of things and of women,
and when restrained within its proper sphere does a great deal of
good. But it certainly has a tendency to deteriorate the char-
acter of women's work, unless they strenuously resist it.

In the general theory of society, women are not expected to
achieve anything. This theory is sometimes the reason that they
are not trained to achieve anything — that their education is so
flimsy and scrappy; sometimes, again, on account of this theory,
so much surprise is elicited when they do achieve ever so little,
that they are flattered into a very dangerous over-estimate of
their own powers. In this flattery there is often concealed the
feeling expressed by Dr. Johnson in his celebrated remark about
a woman preaching: "It is," he said, "like a dog standing on its
hind legs — it is not well done; but then the wonder is that it is
done at all." The tendency of women to nestle within a little
circle of personal friends, and to accept their dictum as the ulti-
mate law of things, renders them as liable to be spoiled by this
sort of admiration, as they are liable to be discouraged when they
do not get any admiration at all.

The remedy for all this, however, is not hard to find. A
woman must accustom herself to dispense with the personal
approbation of the people she knows, as a stimulus for exertion.
She must learn to work for the sake of the work; she must be
ready to put into it an amount of labor as would not "pay" if
estimated merely by what can be seen on the surface; she must
know how to hold her own standard a good deal higher than that of
partial friends; she must learn, not only to keep calm under
blame, but, what is much more difficult for a woman, to bear
praise unmoved, otherwise she will soon cheapen with the praise.
The careful self-education of women in all these matters is so
much the more important, because it is only by means of it that
they can hope to overcome the more external difficulties by which

Inaugural Address 353

they are weighted. It will not do to forget that their health is
often fragile; that they often begin to study somewhat late in life,
and when much needful vitality has been exhausted; that they
are more frequently involved in family responsibilities and com-
plications. At any rate there is always one two-fold dilemma.
They are either pecuniarily well off, and then the force of tradi-
tion tends to keep them from working, because, as it is said, there
is no occasion for it; or else they work — they study medicine, for
instance — under such pressure of pecuniary necessity as leaves
them barely the time or the means for adequate preparation. It
is comparatively rare that the happy mean exists, where the stu-
dent possesses just enough money to secure her from want, yet
not enough to take away the stimulus for exertion. This is
exactly the amount required.

The question of marriage again, which complicates every-
thing else in the life of women, cannot fail to complicate their
professional life. It does so, whether the marriage exist or does
not exist, that is, as much for unmarried as for married women.
In my opinion the increased vigor and vitality accruing to healthy
women from the bearing and possession of children, a good deal
more than compensates for the difficulties involved in caring for
them, when professional duties replace the more usual ones, of
sewing, cooking, etc. But in this delicate and important matter
the facility of adjustment will vary in every individual case.
Many married women will lose all interest in medicine as soon as
they have children, as many now fail to develop the full needed
interest precisely because they have no other, and are dispirited
by isolation from family ties. Many will interrupt their prac-
tice during the first few years after marriage to resume it later.
Whatever is done, either with or without marriage, can evidently
be well done only in proportion as more complete intellectual
development and more perfect training enables the woman to
cope with the peculiar difficulties inherent in her destiny.

Women may be said to have obtained a foothold in medicine
in modern times on account of the sudden development of gynae-
cology. It cannot be said that women have contributed much
towards this development ; but in the treatment of uterine dis-
eases the desirability of women physicians from motives of
delicacy, becomes so evident, that a powerful impulse has been
created in favor of allowing them to practice at least this branch

354 Mary Putnam Jacobi

of medicine. From what I can learn, the majority of women
who study medicine do so with the expectation of at once becom-
ing specialists: and certainly, the majority of persons who think
of consulting them, think of them first and foremost, if not ex-
clusively, in this connection.

Now, nothing can be more certain than, if women are enabled
to practice medicine only in this specialty and for this reason of
delicacy, they must, sooner or later, be again excluded from
medicine altogether. I say again, because as you know or should
know, women have at many different times been admitted to the
privileges of medical studies and practice, but have never gained
so firm a footing that they were not liable to be displaced. The
motive of delicacy; the motive of self-support; the motive of
desire for wider spheres of action, are all perfectly legitimate
motives, but they are extrinsic to the real reason for the existence
of any class of practitioners. This reason is, that such a class is
in possession of knowledge which enables it to understand disease,
and to cure the sick, and which justifies its members in assuming
full responsibility. This full responsibility cannot be assumed,
except after liberal study of the whole field of medicine. If, at
present, here and there a specialist may arrive at distinction who
really only knows one thing : he can only do so because the mass
of the profession know a great deal more. If an entire natural
class of people devoted themselves exclusively to one thing,
they would soon not know even that. Instead of obtaining a
position superior to that of the rest of the profession, they must
sooner or later sink to an inferior one. In the case of gynaecology
and women, the practical experiment has been made : the services
of women have been sought on a large scale exclusively from
motives of delicacy, and you know in what way. The women
were merely assistants — employed to make uterine examina-
tions and report to physicians who were strictly forbidden to
make such examinations themselves. The women experts
learned as little of the subject as Milton's daughters did of the
Latin they read to him without understanding it. The progress
of science was retarded, and their intervention was finally dis-
carded as cumbersome. If women will use this specialty, now
often thrust upon them, as a stepping-stone to general medicine ;
if they will look upon it as the small end of a wedge, and persist
in driving it forward to a larger end; then they may assure their

Inaugural Address 355

position, and that of their successors, by means of this temporary
opportunity. But if they do not obtain a foothold on the broad,
intellectual basis of general medicine; if they content themselves
with claiming this little corner, they will never really gain a high
place even there : they will be driven out, little by little, until at
last the gynaecological wave may pass by, and leave them
stranded. There may be less liability to uterine diseases; or
these may be so much more easily foreseen and prevented that
much less "local treatment" remains to be instituted; or the
sentiments of delicacy may change. Just imagine what would
become of a class of physicians now-a-days who had devoted
themselves exclusively to the treatment of scurvy or of leprosy !
Their occupation would be gone with the disappearance of the
disease; and the boon to humanity would result in ruin to their
class.

I wish now, in concluding, to call your attention to a last class
of difficulties, especially connected with medical schools for
women. These difficulties all arise out of one fact, namely, that
there are not as yet a large enough number of women studying
medicine to support medical schools on a large scale ; and schools
on a small scale are inadequate, because there is no such thing as
large or small in medicine.

During the thirty years which have elapsed since women first
began to study medicine in America, there have always come for-
ward a much larger number to claim the right to practice than to
crave the privilege of being thoroughly well educated. This im-
fortunate majority has been the cause of immense injustice to the
higher toned minority, because they have constantly tended to
drag the conditions of medical education down to the level of
their capacity, or intention to fulfill them. The competent have
often been sacrificed, in order that the incompetent might be
satisfied. A Nemesis never fails to wait upon inefficient intel-
lectual work. It invariably grows lifeless, dull, uninteresting; it
finally ceases from sheer inanition. On the contrary, nothing
more is required to quicken any subject or any occupation into
the most vigorous life and fertile interest, than that every one
engaged in it should be inspired with an ardent desire for knowl-
edge and for high attainment. Whenever people are content to
do a thing in a slovenly and wanton manner, they very soon get
to the end of it. But whenever they try to do it as well as it is

356 Mary Putnam Jacobi

possible to be done, or try to learn everything about it that any
one else knows, they find themselves at the beginning of a task
to which there is no end. They find more to do every day;
every day, also, they find more power to do it.

If all the students of this, or any other school, were thoroughly
imbued with the determination to accomplish the work before
them in the best possible manner, many of the difficulties inher-
ent in the comparative smallness of the school would vanish.
You should learn to look at yourselves as a colony just landed in
a new country; compelled to found a state in spite of hardship,
and peril, and danger, and isolation, by means of the vigorous
and intelligent co-operation of each of its members. I do not
know that any more instructive reading can be found than the
history of colonies, a theme with which every American certainly
should be thoroughly familiar. In studying the various destinies
of the early settlements of this country, you may gather many
hints of importance applicable to our present situation. For us,
also, the sea has been traversed, the landing effected, the howling
savages, represented by the medical students, temporarily
repelled. But that is about all which has as yet been done. It
remains to be seen whether our colony contains in itself the stuff
out of which the Bay State was built up; or rather those vicious
and corrupting elements which corroded to destruction so many
settlements south of the Potomac. And do you know what was
the one predominating influence that led to such destruction?
It was that the mass of gentlemanly emigrants, who had not
learned how to dig, and who were by no means ashamed to beg;
who had left the mother country, not to seek an opportunity to
work more, but to work less; to shirk all the work they possibly
could ; to profit by the industry and courageous patience of their
companions, in order to share, without due share of labor, the
revenue accruing from their tobacco and their corn. These are
not the characters which could have founded Massachusetts and
laid the corner-stone of that State, where, a century later "em^
battled farmers could fire the shot that echoed round the world."

Theirs is the stuff, these are the characters, this is the austere,
self-denying, intelligent heroism, which is needed for our enter*
prise — for this also still deserves to be called heroic.

SPECIALISM IN MEDICINE '

We propose to consider briefly, but critically, the following
proposition, which, though not distinctly formulated, is, as it
were, held in solution in many others now current, and may be
easily precipitated from them.

At the present day medical science has expanded to such an
extent that its intelligent cultivation as a whole by any one per-
son has become impossible. The practice of medicine, therefore,
to the extent to which it may reach any really high standard of
excellence, must henceforth be carried on exclusively by special-
ists.^

Thus, the physician, who should, in chimerical imitation of
Lord Bacon, propose to "take all (medical) knowledge for his
portion," must, on this theory, be consigned to a limbo of wornout
inanities. Nevertheless, the most useful functions of special-
ists are still exercised with tacit reference to the intelligent prac-
titioner, who is compelled, not indeed to know all about all
medicine, but to hold the key of admission to any of its branches,
of which, at any moment, he may have practical need.

Thus, specialists are justly expected to become the deposi-
tories of special literature, and to so sift, handle, classify, and
arrange this, that it become accessible to, and utilizable by the
general practitioner. By reiterated experience, they are expected

' Reprinted from the Archives of Medicine, 1882, vol. vii., — Editorial Depart-
ment.

» . . . "The fact, the hard and undeniable fact, that all intelligent and
scientific physicians are quasi-specialists, and must be. In the present develop-
ment of medical science there is no alternative; a physician must be a quasi-
specialist, or possess a universal knowledge of a superficial, mostly booky kind,
— a knowledge wholly insufficient to insure intelligent or successful practice."
E. C. Seguin, these Archives, April, 1881, p. 186.

357

358 Mary Putnam Jacobi

to acquire an exceptional familiarity with certain types of disease,
so as to be better able to decide in rare, obscure, or unusually
difficult cases, when the physician shall call them in. By con-
tinued application they may tend to indefinite improvement in
the technique of diagnosis and of treatment. Finally, in regard
to the state of medical knowledge on any given question at a
given moment, they may furnish the standards with which the
knowledge and practice of the general physician must constantly
be compared and tested. Thus, specialism is largely useful in
furnishing the exact material with which the general physician
may make his practical combinations. In his absence, and from
the languid interest which specialists profess in each other's
departments, this combination would often not be effected. But
the problem offered by a sick person is always a problem of com-
bination. The practical specialist does not analyze, but roughly
divides this problem according to considerations frequently
artificial. The scientific specialist abstracts phenomena com-
pletely; studies separately, anatomical, physiological, chemical,
pathological conditions. It is the ideal business of the physician
to take conditions which science has abstracted for the purpose
of thought, and to recombine them for the purposes of life. In
the absence of the physician there would be no one to do this;
with every new deterioration of the ideal character of the general
physician, this work of combination is less and less well done.
As a consequence, every sick person who can pay for it begins to
expect to divide up his body among a cluster of "eminent special-
ists" before any positive diagnosis of his case can be reached.

Notwithstanding the inconvenience and expense of this pro-
cedure, it tends to gain in popularity on account of the simplicity
and apparent common-sense of its theory. The laity are very
ready to infer not only that specialism is good, but that the more
of it the better. If the physician who treats six diseases is
necessarily superior to him who is willing to manage sixty, then
he who confines himself to one must be the best of all. Hence
the popularity of the pile doctor, and the cancer doctor, et hoc
genus omne.

The great principle of unity in diversity, whose research is
the problem of philosophy, is also the animating principle of
philosophical medicine. But this cannot be appreciated by
persons who are neither physicians nor philosophers.

Specialism in Medicine 359

The complete theory of practical specialism admits that a
man may be a shining light in a subject "which interests him,"
yet a perfect idiot in another of equal importance to the patient.
Now, the initial problem of diagnosis is the decision of the de-
partment to which the case belongs; and, on the above theory,
the fate of the patient must be a matter of chance. If his case
happen to fall on the competent side of the doctor he consults,
well and good; but if not, it must fail of recognition. No fixed
value can be attached to any symptom, when it is remembered
that the lines of disease intersect each other in every direction.

Thus, does a young girl fall into a melancholy? The question
would arise : Shall she be at once entrusted to the gynecologist on
the suspicion of uterine disease, or to a hasmatologist for chloro-
anaemia, or to the superintendent of an asylum as a case of in-
cipient insanity, or to a friend of the family to bring about a
thwarted project of marriage? If a woman has a pain in her
back, how many physicians must be consulted before deciding
whether this be due to muscular denutrition, or to uterine dis-
placement, or to chronic nephritis, or incipient myelitis, or to
commencing caries of the vertebra, or merely to hysteria? When
a typhoid fever simulates general tuberculosis, or the reverse,
should the diagnosis be made by the heart and lung specialist,
or by the fever doctor ? When a man falls down in an apoplexy,
does his case belong to the neurologist, or to the specialist in
diseases of the heart whence an embolus may have been carried,
or to the practitioner devoted to gout and atheroma? Shall a
children's doctor decline to perform an urgent tracheotomy
because he is not a surgeon ? or shall a physician tolerate irrepar-
able delay in reducing a dislocation for the same reason? ^

It is sometimes said that the conscientious specialist will be
sufficiently trained in general pathology to recognize when a sub-
ject lies beyond his domain, and he will then, "in justice to his
patient," hand him over to one of his own "eminent colleagues."

Dr. Barnes, who, of all gynecological specialists, most fre-
quently deprecates specialism, thus illustrates the case: "A
woman comes to him complaining of pruritus. Much to her
astonishment, he examines her urine, because he retains enough

' We have within a few weeks seen two cases of irreparable injury caused by
just this fact, and by the prolonged application of poultices instead of prompt
operative interference.

36o Mary Putnam Jacobi

knowledge of general pathology to know that pruritus may indi-
cate diabetes. Finding sugar, he at once resigns the case and
sends her elsewhere." This illustration represents a class of cases
which do often occur, and where the specialist is really both com-
petent and conscientious the case may be managed without
further inconvenience to the patient than that of a double con-
sultation. But — and this is a practical inconvenience of per-
haps a low order for mention here — there is certainly no more,
but rather less, guarantee for the honor of a specialist than of a
general practitioner. The last is expected to take charge of
the patient whatever may prove to be the matter with him. His
interest, therefore, in ascertaining the exact state of things is
identical with that of the patient. But the specialist knows
he will only be entrusted with the case if he can prove that it
falls within the limits of his own specialty. He is therefore
always under a strong temptation to "make out a case," and for
this purpose, if necessary, to rather avoid than to seek close
scrutiny of the surroundings.

We hasten to recognize the fact that there are many specialists
of honor as high and unsullied as could be claimed for the most
upright physician. But we think the existence of the special
temptation we have referred to can hardly be doubted, nor that
this temptation is by no means always resisted. Apart from this
purely practical consideration, it is to be remembered that such
definite grounds of classification are more often absent than pres-
ent ; the specialist confronts the theoretical difficulty of not being
quite sure what he is to exclude.

Another important inconvenience in the tendency to universal
specialism is that the beginnings of disease are so often likely to
escape detection. To consult a specialist, the patient will first
wait until he is pretty sure he has the specialist's disease; thus, he
must wait until this is rather well developed. Thus, too often
no attempt is made to treat a chronic disease until it has become
almost incurable, nor to make the precise diagnosis of an acute
disorder until it has nearly killed the patient.

But the collapse into inefficiency of a general practitioner is
not an adequate basis upon which to develop an accomplished
specialist. Instead of either the one or the other, we obtain a
confused, vague, cheerfully optimistic "family doctor," who re-
lieves himself of responsibility for one organ in his patient's body

specialism in Medicine 361

after another on the ground that it belongs to some "specialist,"
who, as long as symptoms are not importunate, declares that
they will "pass away of themselves," — instinctively dreading the
recognition of their importance as the signal for a surrender of
the case. Thus, epitheliomas are allowed to extend until they are
ineradicable, and chronic pneumonia to eat out caverns in lung
tissue unsuspected, and the child to limp from habit into a sup-
purating coxitis, and the melancholic to commit suicide while
sent on a journey for change of scene.

In addition to the functions which may be unquestionably
fulfilled by specialists with great advantage to the community at
large, other claims are often advanced of, we believe, less validity.
Thus, it is said:

1. That to specialists alone, or chiefly, is due not only the
improvement of technique, but the discovery of the fundamental
ideas which change the face of science.

2. That specialists are habitually engaged in life-long re-
searches in the subjects of their specialty.

3. That, thus, the patients of a specialist must profit much
more by his intellectual activity than can the patients of a general
practitioner by his.

4. That, whereas a general practitioner can only have at best
a partial acquaintance with the many diseases he treats, the
specialist, in virtue of his wise limitation of observation, can
know all about his.

5. Finally, that the establishment of specialities alone per-
mits the accumulation of clinical material in definite and avail-
able masses.

The first claim might be contested a priori from the considera-
tion of the evident necessities of the case. No idea in a specialty
can be as fundamental or as original as that on which the spe-
cialty is founded, and this evidently must have been suggested
by a non-specialist. Laennec was not a specialist when he
practically discovered the principles of auscultation; his pro-
longed special application afterward was devoted to the consoli-
dation and simplification and detailed establishment of his theory.
Helmholtz was no oculist when he invented the ophthalmoscope ;
even his treatise on optics was written later. Czermak was not
a specialist when he invented the laryngoscope. Orthopedics,
perhaps, dates its modern impulse from the researches in locomo-

362 Mary Putnam Jacob!

tion of the brothers Weber, who were physiologists. The prin-
ciple of counter-irritation in joint diseases was established by
Pott, a general surgeon of London; the still more important
principle of rest was elaborated by Bonnet, a general surgeon of
Lyon. The effective introduction into orthopedic surgery of
resection was made by Sayre before he became an orthopedist.
In gynecology the capital operation of ovariotomy was initiated,
as is well known, by McDowell, a general surgeon, having been
originally suggested by Hunter, than whom none of the great
physicians of the eighteenth century was less of a specialist. It
was the great surgeon Belpeau, and the author of a treatise on
neuralgia, Valleix, who first called attention to uterine flexions
and suggested pessaries. Dr. Sims had hardly become a special-
ist when he invented his speculum and contrived his operation
for vesico-vaginal fistula, achievements which his long career has
never enabled him to excel.

Modem dermatology is based upon anatomical researches,
which may be, and often are, carried on by histologists who do not
practise medicine at all, — hence could not be called practising
specialists. The clinical researches of the French school, being
conducted according to the theory of diathesis, were not and
could not be made by physicians limited in clinical observations
of skin diseases. The theory may be discarded ; but the results
of the impulse given under its influence remain. In neurology
clinical specialism was first suggested by anatomy, and later by
physiology. In no practical specialty is modem clinical obser-
vation kept more closely to these two fundamental sciences than
in this. The principal facts and ideas have come from anatom-
ists or physiologists, or from non-specialists, who have also
furnished the chief clinical groupings. Bell's discovery of the
double function of the roots of nerves was made in his capacity
of anatomist; his discovery of external facial paralysis, in his
capacity of general practitioner. Marshall Hall, Brodie, Aber-
crombie, Calmeil — even Broussais, with his "De 1' Irritation
et de la Folic," — and a host of others, who were the early pioneers
in this century in the study of nervous diseases, were not special-
ists, since it was indeed at that time not possible to be one.
Nevertheless, many of their observations remain of permanent
and fundamental value. The most eminent physiologists, who
have contributed to knowledge of nervous diseases far more

specialism in Medicine 363

than have simple clinicians, have not been specialists in the
physiology of the nervous system. Magendie, who divides with
Bell the honor of the discoveries in the spinal roots of nerves,
wrote two volumes on the "Physics of the Animal Organism."
Bernard is as distinguished for his composite researches in
diabetes (to go no further) as for those on the vaso-motor system.
Schiff, who distinguished the paths in the cord for different
sensory impressions, has written a treatise on digestion. Neither
Tiirck nor Bouchard were practical specialists when they estab-
lished the fact of descending degenerations; nor was Waller when
he made the famous experiment which has served to explain
these morbid processes. Brown-Sequard's researches in epilepsy
were made at the very beginning of his career, and not when
he had become a specialist. The clinical groups of locomotor
ataxia and pseudo-hypertrophic paralysis were established by
Duchenne, whose specialty was not nervous diseases, but faradic
electricity, and originally, in its application to orthopedics. Ex-
ophthalmic goitre has been discovered by Basedow, a sagacious
general practitioner; and the same is true of Addison's disease.
Gubler, the first to point out crossed paralysis, was never a
specialist; indeed, his essay on the hepatic lesions of hereditary
syphilis is as famous as any that he has written. Sir William
Gull's and Stanley's observations on paraplegia from renal cal-
culus initiated research into "reflex paraplegia." No one could
suppose them to be specialists.

Another class of examples is offered by writers who had
become specially identified with neurological practice before
publishing the treatises now recognized as authoritative, yet
who, before this, had achieved distinction in other directions.
Thus, Griesinger's now classical work on psychiatry was pre-
ceded by an only less famous treatise on infectious diseases.
Ley den, before writing two volumes on diseases of the spinal
cord, had published a valuable monograph on icterus. Noth-
nagel's admirable clinical contributions to the problem of cerebral
localization, and his less admirable experiments on the brain,
cannot efface recollection of his hand-book of therapeutics — on
the whole, the most valuable extant on the subject. Charcot
began his studies in neurology by general studies on the diseases
of old age. He was stimulated by the practice of no specialty,
but simply utilized the neglected pathological materials accumu-

364 Mary Putnam Jacobi

lating in oblivion at the Salp^tri^re. Only recently, moreover,
Charcot has published a series of lectures on the pathology of the
liver and of the kidney; and his description and analysis of the
lesions of broncho-pneumonia have thrown new light on a sub-
ject supposed to have become hackneyed.

These examples, selected at random, do not of course exclude
the clinical discoveries or inventions which have been made by
practising specialists, and in a manner which indicates that they
were the direct outgrowth of their special clinical experience. In
neurology, Westphal's discovery of the tendon reflex symptom;
in gynecology, Emmet's operation for lacerated cervix, are typical
examples of this class. The fact that Hitzig, whose discoveries
on the motor irritability of the cortex have had such an enormous
influence, has been for a long time the superintendent of an
insane asylum, is not an example of the influence of practical
specialism. His researches were purely physiological, and were
suggested by physiological considerations, which clinical obser-
vations might confirm, but did not suffice to originate.

We think the cases quoted are sufficient to demonstrate that
indefinite repetition of clinical experience is never of itself suf-
ficient to suggest new ideas; that a life-long specialism in no wise
predisposes to discoveries, and still less is essential to their
achievement ; that in a large number of cases, if not the majority,
the consecration to a specialty has followed, and not preceded, the
discovery which has achieved the reputation of the specialist,
and has fascinated him, perhaps for ever, with the subject. But
it is always genius which invents; special application can only
improve; it then remains for culture to appropriate.

Our limits compel us to be brief with the three remaining
propositions. In regard to the second claim, namely, the life-
long researches supposed to be carried on by practising special-
ists, we would call attention to a fact usually overlooked. It is
that for every mind, in regard to every subject it studies, there
exists a saturation point of suggestiveness, which is not exceeded
by enforced prolongations of attention. It is very useful for a
person to pursue a subject, so long as it continues to yield him
ideas; very useful to practise a technique, until it be sufficiently
mastered to meet all difficulties of execution. But afterward
there remains no intellectual advantage in persistent adherence
to the same line of thought. There are personal, often pecuniary

Specialism in Medicine 365

advantages; there is profit gained from an acquired reputation
and previous labors. But this, however legitimate, is a very
different thing from continued progress in science, or indefinite
improvement in care-taking of patients, such as is generally
assumed.

Again, the practical specialist does not, fortunately, often
select only one disease, but one organ, or presumably associated
group of organs. Now cases of the same disease in different
organs are apt to present many more points of resemblance than
do cases of different diseases in the same organ. There is much
more analogy between uterine cancer and epithelioma of the lip
than between uterine cancer and uterine flexions. The study of
the pelvic curves throws no light on embryology, although both
subjects are assigned to the obstetrician. Uraemic peritonitis is
better understood by study of septic peritonitis than of renal
calculus. Epilepsy has much less resemblance to the systemic
forms of myelitis than to the eclampsia induced by acute hemor-
rhages, and so on.

Practical specialism only enforces attention to clinical obser-
vation : analysis of this, on the basis of any special science, is as
optional with the specialist as with the general practitioner, and
as liable to be neglected. Many good specialists are purely
clinicians; many others, really distinguished in some branch of
science connected with special disease, are quite innocent of
others. Perhaps from few experts in consultation would we ex-
pect familiarity with such a monograph as Bert's on respiration,
or with the complex laws on diffusion of gases. It would not be
difficult to name neurologists distinguished in experimentation,
but who have never mounted a section of nerve tissue for the
microscope. It would not be impossible to cite skillful surgeons,
most ingenious in mechanical contrivance, who are unaware of
the pathological anatomy of the tissues they divide or remove.

Great as are the difficulties arising from the great increase in
the mass of knowledge, there are many palliations. The per-
fected machinery for sifting, analyzing, classifying, and sorting
this knowledge, renders it ten times as accessible and compre-
hensible as was formerly one tenth part as much. Many gen-
eral principles have been established, which link together, in
lucid unity, hosts of details, once unconnected, unintelligible,
and hence most difficult to remember. The classical body of

366 Mary Putnam Jacobi

doctrine in medicine, whose possession is essential to the practice
of medicine {secundum artem), is really more accessible to-day
than at epochs when some narrow system professed to crush it
into a portable nutshell. Finally, the advance of science and of
scientific method exacts, that who would claim to contribute to
further progress must concentrate himself much within the limits
of any conventional specialty. No one disease, no one organ
may be compassed by a single observer: happy he who may, by
laborious research, contribute to the solid establishment of a
single detail of the truth. For such work it is, theoretically at
least, as easy for the general, as for the special physician to with-
draw a certain portion of his attention from practice. Neither
can hope that his research can benefit more than a small propor-
tion, if any, of his own patients. The one must, as much as the
other, depend on the collaboration and unconscious cooperation
of a thousand workers. For both, are needed not only clinical
observations, but the mental ability to utilize observations, —
a mental training in the art of handling large masses of ideas.
For both, if we may judge from European examples, the personal
experience to be gained in private practice is insufficient ; to both,
should classified hospitals be open as the true field for pathological
study.

SHALL WOMEN PRACTICE MEDICINE? ^

The continually renewed discussion, on the part of society,
concerning the sphere, capacities, rights, functions, duties, and
allowable occupations of women may well seem, from some
points of view, rather ridiculous. We may justly ask why
women require so much more discussion and preachment than
men; and may even decide that the argument is largely super-
fluous, and the sermon often impertinent.

Further consideration, however, discloses several grounds of
justification for this social habit, from which, in any case, it is
quite impossible to escape. In the first place, women, as the
most malleable part of the social organism, are destined to re-
ceive the first, and also the most lasting, impress of prevailing
social opinions. They transmit — the phrase is becoming classi-
cal— the organized experience of the race. The least change in
such experience affects them especially, and hence they must bear
the special brunt of the criticism upon it.

In regard to the particular subject we propose briefly to con-
sider, social opinion is of very real importance. Success in a
professional career necessarily depends, to a large extent, on the
taste of the community. There must be a readiness to consult
women physicians; a willingness to educate them; a sufficiently
wide-spread desire on their part to be so educated. If the social
prejudice be very strong, no young woman will dare express the
wish to study medicine. Should the vagrant fancy arise, it will
be promptly checked, as something eminently improper, — like
going on the stage, or dancing on the tight-rope at a circus. That
considerable numbers of women do now study medicine and sup-
port themselves by its practice, is itself a proof that the prejudice
of thirty years ago has somewhat abated. Women are admitted,

' Reprinted from the North American Review, January, 1882.

367

368 Mary Putnam Jacobi

in America, to the State universities of Michigan and of Cali-
fornia, and sustain, moreover, three separate schools: one in
Philadelphia, one in New York, one — the youngest — in Chicago.
In Europe, they study at the universities of Paris, Zurich, Berne,
Upsala, Ley den; have a separate school at St. Petersburg, and
are admitted to examinations for degrees at the University of
London, and also at Dublin. They are members of various
medical societies, contribute to various medical journals, conduct
hospitals, perform surgical operations, build up practice, and in
other ways seem to conduct themselves and to be treated like
other members of the medical profession.

Yet discussion still continues, and although the once contin-
uous opposition has become intermittent, its crises are perhaps
rendered more noticeable on that very account. The centennial
meeting of the Massachusetts Medical Society was agitated by a
renewal of the controversy concerning the admission of women
physicians. Their cause found vigorous champions, but was
defeated, when an equally vigorous opposition supported the
majesty of precedent, by the tactics of parliamentary maneuver-
ing. The siege at the gates of Harvard, destined to be as mem-
orable, we believe, as that formerly laid against Thebes, is still
maintained. The echoes of the fierce battle waged in the Uni-
versity of London have scarcely died away; a few years ago,
the Society of German Naturalists, meeting at Berlin, voted to
"purge itself of the presence of women"; and only last summer,
public attention was called to the formal exclusion of women
from the International Medical Congress, at its first meeting
held in England. The measure, it is said, was taken in obedience
to the wishes of the Queen, and certainly to those of the court
physician. Sir William Jenner.

All innovations excite opposition. But it is difficult to ac-
count for the peculiar bitterness of the opposition which has
been manifested to the admission of women to medicine, when it
is remembered that this admission is no innovation at all. Wo-
men practiced freely in medicine so long as the practice of medi-
cine was free, and entrance upon it was decided merely by natural
taste for dealing with the sick and ministering to their infirmities.
When, however, instruction in medicine began to be systema-
tized, when universities took charge of it, and legal standards
of qualification were established, women were excluded, because,

Shall Women Practice Medicine ? 369

at the time, no one thought of them as either able or wilHng to
submit to the new conditions imposed. The monastic discipHne
out of which universities had emerged still molded their etiquette
sufficiently to render them inaccessible to women. The women
themselves do not appear to have thought of presenting them-
selves as candidates for a university education. Thus, in the
onward current of progress, the women physicians of the Middle
Ages, or, in France at least, of all the centuries preceding the
Revolution, were dropped on the bank. Women are now merely
endeavoring to reenter the stream, by adapting themselves,
whenever they are allowed to do so, to the changed conditions
of things.

In this effort, the most serious obstacles to be encountered
are not always the most real ones. In this, as in everything that
women do, the question of capacity is often outranked by the
question of taste. Whether woman, with all her organic imper-
fections on her head, can be theoretically supposed capable of the
study and practice of medicine; whether, which is quite a dif-
ferent question, there actually exist any number of women whose
capacity in this direction has been fairly tested and demonstrated,
— these are interesting subjects of inquiry. But the most com-
pletely affirmative answer to such inquiry might still leave un-
settled a question of much more importance for that large class
of people whose convictions and actions are under the permanent
domination of their tastes. These ask not, "Is she capable?"
but, "Is this fearfully capable person nice?" Will she upset our
ideal of womanhood, and maidenhood, and the social relations of
the sexes? Can a woman physician be lovable; can she marry;
can she have children ; will she take care of them ? If she cannot,
what is she? "Qu'est ce qu'unefemme," said a French journalist
in this connection, "qui n'est ni Spouse ni mere?" "God," de-
clared a Boston physician, well versed in the counsels of Provi-
dence, "never intended women to practice medicine." Hence
the inference that piety, if nothing else, demanded the exclusion
of women from the Massachusetts Medical Society.

It is from the peculiarity of the conditions involved, that the
handful of women now engaged in the practice of medicine may
be considered in any way to affect or endanger existing arrange-
ments or social ideals. Thousands of women, from manifold
causes quite extraneous to medicine, remain celibates all their

370 Mary Putnam Jacobi

lives; yet no one reproaches them for refusing the duties of wife
and mother. Thousands of women earn their living by non-
domestic labor; one profession, that of public teaching, practically
thrown open to women only during the last half-century, is al-
ready thronged by them. Yet no one feels that the foundations
of society are therefore liable to be overthrown. What is it in
the profession of medicine which excites, at present, such different
feeling and such bitter prejudice?

There are several things. In the first place, the profession
of medicine has always been subjected to popular misconcep-
tions, and the odium due to these is necessarily shared by the
women who aspire to be physicians. Again, by a social fiction,
it is assumed that the usual employments now sought by women
are to be filled by them only while waiting for marriage, or as a
resource in widowhood or desertion. Even such professional
work as teaching is expected to be laid aside after a few years,
and there is much, at least in the primary grades of teaching, to
make such interruption rather desirable. But the profession of
medicine must be chosen deliberately, and not at hap-hazard;
from a strong and genuine taste, and not from the mere press-
ure of economic necessity; it must be seriously prepared for in
youth; must be entered upon at the age at which at present
many women marry; does not yield its best returns until full
maturity has been reached; must be adopted, therefore, if at all,
for a life-time. Hence is required either an accidental celibacy
or a deliberate renunciation of marriage for the sake of medicine,
such as is not dreamed of in regard to any other work; or else
such an adjustment of domestic claims as shall render them and
the practice of medicine by married women mutually compatible.

But further, apart from the special odium attaching to medi-
cal knowledge, the assumption of capacity on the part of women
for any knowledge which leads to first-class responsibilities
offends the average social ideal. Again: The idea of mental
training as a means of developing force is rather new to the
world in any aspect. It is practically almost unthought of in
regard to women, who are habitually estimated by the measure
of their native, untrained capacities. This is seen to be inade-
quate for the responsibilities of medical practice.

To consider a little in detail the foregoing topics. The as-
sertion that medicine and physicians are permanently and pro-

Shall Women Practice Medicine? 371

foundly misunderstood by the public may not at once be accept-
ed. Yet, it is certain that, despite the familiarity of his presence
and appearance, the laity know less about the doctor than about
any one else with whom they have to do. They cannot under-
stand why he wants to dissect, or to "vivisect," or to make post-
mortem examinations; why he stickles for a punctilious etiquette;
why he is fascinated by repulsive objects; why he can find fathom-
less mysteries in the commonplace miseries which they have to
endure; and how, by any process of reasoning, the recondite
connection between these mysteries can be detected and made
clear. The handling of familiar things in an unfamiliar way is
a process inevitably bewildering to the uninitiated spectator.
There is something uncanny about it. Moreover, the human
body has ever been esteemed sacred. From the Egyptian em-
balmer down, those who have dared to intrude upon its mysteries
have been branded as profane. When, from the pressure of
evident necessity, the profanity has been tolerated, the tolera-
tion has only half-repressed a shuddering horror at the sacrilege.
The violent popular excitement recently aroused in fox-hunting
England against physiological experiments — ^with such effect
that they have been practically forbidden by legislation — recalls
the still more violent agitations in the last century against
"body snatching," and the legislative repressions of anatomical
studies. Mr. Tennyson, in one of his latest poems, draws a
caricature of the most humane of professions in the person of
a "red-bearded" student from "the hellish schools of France."
In 1794, Mrs. Shelley, in her romance of "Frankenstein," stig-
matized the sublime search after the origins of life as "dabbling
in the filthy secrets of the grave." The same sentiment really
animates the modern poet-laureate and the wife of the elder poet;
although in recent times exquisite experiments have somewhat
redeemed the theme of the spontaneous generation of life from
the realm of "filthiness," and the " anti- vivisection " prejudice
drapes itself in the pretext of philanthropy. But at bottom the
feeling is identical. Life is a mystery ; the attempt to penetrate
mysteries is a sacrilege; and terror of the awful, unknown conse-
quences of sacrilege is quite sufficient to overpower the reason-
able apprehension about intrusting the care of sick bodies to
persons who have been forbidden to learn anything about them.
Now, the introduction of women into a sphere regarded as at

372 Mary Putnam Jacob!

once dirty, horrid, and irreverent certainly shocks many of the
"finest sensibilities of our nature." The feminine university
founded by Tennyson's lovely Princess had, among all its schools,
"not one anatomic." She could not bear

" txD ape

The monstrous male, who carves the living hound";

and only in the spirit of the sublimest self-sacrifice could she,
fearing casualty, be induced,

" through many a weary month.

To learn the craft of healing."

The poet does not seem to doubt her capacity for mastering this
wearisome business, but evidently feels that the Princess would
have been alienated from poetic sympathies had she found the
task other than repulsive — had she delighted and gloried in it
as a real physician must do. In this estimate, he strikes the key-
note of average popular sentiment.

That the study of the mechanism of the human body is not
mere dirty work, but one of the most sublime occupations; that
mysteries are not sacred, but embarrassing masses of ignorance
destined to be dispelled; that the sensuous disgust attendant on
anatomical and physiological research can be, and is, completely
consumed in the divine flame of an idea; that human life is
more precious and more deserving of reverence than any of the
accidents, physical or social, by which it is environed — these con-
victions have been steadily pressed against the inert minds of
the unreasoning multitude, until they have at last secured for
themselves toleration, if not acceptance. The odium attaching
to the study of medicine by women must be overcome by similar
means. The charge of ' ' unsexing themselves ' ' by the acquisition
of the particular kind of knowledge required in medicine is, after
all, less formidable than that of "dehumanizing themselves,"
which, in one form or another, has so often been brought against
men for the same thing. With those whose beliefs are not a
matter of reason but of habit, the mere repetition of a fact until
it becomes habitual is sufficient to insure acquiescence. This cir-
cumstance goes far to compensate the inconvenience of the preju-
dice engendered by the mere fact of unfamiliarity.

Touching closely upon the universal prejudice which is prim-
itively rooted in the terror of sacrilege, comes another, which, at

Shall Women Practice Medicine ? 373

the present day, is held almost exclusively in regard to women.
It is often said that the work of practicing medicine is necessarily
so coarse and disagreeable, that none but coarse and disagree-
able people are naturally fitted for it; or, if others engage in it,
they must inevitably deteriorate to an inferior personal and social
level.

Now, the people who advance these statements have often
themselves been sick — have had, therefore, frequent personal
intercourse with physicians. It is, therefore, pertinent to inquire
whether these delicate ones have always found their own phy-
sicians to have been rough-shod brutes, or whether they consider
that the task of ministering to their infirmities in any way
necessitates coarseness and harshness ? The tacit answer to this
inquiry is, we believe, that refined people would never do any-
thing so eccentric as to consult a woman physician. She must
perforce "go about among all sorts of people," pick up her prac-
tice where she can, and the process of "going about" is often
alluded to as if it implied carrying a revolver, or seeking the
escort of a policeman.

Of all the social bewilderments with which this question is be-
fogged, this is, perhaps, at once the most ridiculous and the most
exasperating. It is impossible to imagine a sphere in human
life, with the exception, perhaps, of the artistic, in which delicacy
• — mental, moral, and even physical — is more essential than in
that of the physician. The preservation of decorum, the main-
tainance of suitable reserves, the just balance of rights, the quick
perception of feelings, all these are the natural correlatives of the
deft physical touch, of the intellectual subtlety, which should, and
which does, characterize a true physician. What is there in all
this incompatible with the classical, not to say conventional, ideal
of feminine character?

There is another consideration more excusably overlooked.
It is impossible to be a physician on the basis of personal sym-
pathies alone. If the interest in the disease be not habitually
greater than the interest in the patient, the patient will not
profit, but suffer. He may gain a nurse, but he loses a physician.
Now disease, even more than death, tends to level distinctions.
It diminishes the social value of those who have any ; but, on the
other hand, it invests with an otherwise unattainable interest
those who are quite lacking in social charm — the stupid, the

374 Mary Putnam Jacobi

vulgar, and even the vicious. The physician is, indeed, the only
person who can "go about among all sorts of people," unbored
and uncontaminated. When the priest does the same thing, it
is because, as far as may be possible, he imitates the bearing of
the physician.

The only possible excuse for this wide-spread assumption,
that women physicians must be inferior to men in personal re-
finement and social culture, may be found in the conditions under
which women have hitherto been obliged to study medicine.
The obloquy heaped upon women students of medicine has been
so great that many women of refinement have been repelled
from a pursuit to which their natural taste inclined them. Con-
versely, many women have entered upon it without taste or
understanding, but merely attracted by the flavor of notoriety
and the enjoyment of something slightly turbulent and very
eccentric. Not these ignorant women, but society, are to blame
for the opportunity accorded to put forth their absurd preten-
sions. A Nemesis waits upon the rejection of just demands.
The refusal to admit to a disciplined education and to submit
to suitable tests the women who were really fitted for both, has
merely resulted in the rather extensive education of the unfit;
and this has often been carried on in the very least suitable
manner which human ingenuity could devise for the purpose.

Considerations of delicacy have been urged, as is well known,
in a special manner, both for and against the admission of women
to medicine. On the one hand, the association of women with
male students in professional schools and medical societies, has
been denounced as an indelicacy which rather more than borders
upon immorality. On the other hand, the treatment of female
patients by male physicians — especially in a certain class of
diseases — is shown to involve a straining of delicacy which cannot
but be most undesirable, even when it is submitted to as inevit-
able. In the most populous quarter of the globe, in all the coun-
tries of Asia, it is known that such submission is not considered
inevitable — is, indeed, not allowed. The alternative is invari-
ably accepted of leaving the female half of the community entirely
unprovided with medical attendance for any disease whatever.*

' To THE Editor of the Pall Mall Gazette.

Sir: The October number of the "Indian Female Evangelist" supplies
an interesting piece of evidence on the disputed point as to whether properly

Shall Women Practice Medicine ? 375

No hard names which have ever been heaped upon the women
who want to study medicine can exceed those once lavished on
the presumptuous men who first forced their way into midwifery.
As late as the seventeenth century, even at the time that Cham-
berlain was inventing the forceps, the term "man midwife" was
as much a term of reproach as that of "female physician" often
is at the present day. The feeling of delicacy, permissible, even
imperative in itself, was compelled to yield to the still more im-

educated medical women would or would not be acceptable to the native
ladies of India. It appears that the Maharajah of Punna, in Bundelcund,
applied to Miss Beilby, a female medical missionary at Lucknow, to treat his
wife, who had long been suffering ffom some painful internal ailment. Miss
Beilby spent some weeks in attendance upon the Maharanee, and happily was
able to effect a cure.

When the time of her departure from Punna arrived, she was desired to
present herself at the palace to take leave of her royal patient, on Wednes-
day, the 13th April last. The Maha-Rani received her in her private room,
and almost immediately dismissed all her attendants and ladies, so that she
might be quite alone with her. The Maha-Rani then said she wished Miss
Beilby to make her a solemn promise. Without knowing what it might in-
volve, she was reluctant to do this, but at length the Maha-Rani said: "You
are going to England, and I want you to tell our Queen and the Prince and
Princess of Wales, and the men and women in England, what the women in
the zenanas in India suffer when they are sick. Will you promise me to do
this?" She explained that it was no social change in their condition she
sought, but relief in their cruel sufferings. She charged Miss Beilby to give
this message herself to the great Queen of England; not to send it through
any other channel, but to take it herself, or her Majesty would think less of
it. Miss Beilby represented to the Maha-Rani the difficulty she would have
in getting access to the Queen — that with us it is not as in the East, that
any one can go to the palace and lay a petition before the native sovereign.
Besides, she told her she hardly knew what good it would do if she could do
as she wished, and take her message to our Queen. The Queen could not
make lady doctors, or order them to go out. It was not in the power of even
the great Queen of England to do this. "But," said the Maha-Rani, "did
you not tell me our Queen was good and gracious, that she never heard of
sorrow or suffering without sending a message to say how sorry she was, and
trying to help? Did you not show me a picture of a train falling into the sea,
where a bridge broke, and did you not tell me how grieved our Queen was?
Well, it was very sad those people should have been killed, but our condition
is far worse; if you will only tell our Queen what we Indian women stiifer
when we are sick, I am sure she will feel for us and try to help us." Miss
Beilby felt she could no longer refuse to promise to convey this message, if
possible. The Maha-Rani next bade her write it down at once (giving her
pen, ink, and paper), lest she should forget it, and added, "Write it small,
Doctor Miss Sahiba, for I want to put it in a locket, and you are to wear this

376 Mary Putnam Jacobi

perative claims of superior knowledge and capacity. If this has
ever been accomplished, it is not doubtful that a legitimate feel-
ing of delicacy — as that which makes many (not all) women dis-
like to be treated for at least uterine diseases by a man — should,
if once thoroughly reenforced by legitimate confidence in feminine
skill, overpower the quite superficial ideas of delicacy in regard

locket round your neck, till you see our great Queen and give it her yourself.
You are not to send it through another."

On reaching England, Miss Beilby communicated with some of the ladies
about the Court, and on July 13, 1881, the Queen received her at Windsor
Castle:

Her Majesty listened to Miss Beilby's statement with great interest, asking
mapy questions, and showing the deepest sympathy. Turning to her ladies,
she said: "We had no idea it was as bad as this; something must be done
for these poor creatures. " The Maha- Rani's locket with its message was given
to the Queen, and Her Majesty entrusted Miss Beilby with a message in reply,
which was intended for the Maha-Rani alone. But the Queen also gave Miss
Beilby a message which might be given to every one with whom she spoke on
the subject of the poor suffering Indian ladies: — "We should wish it gener-
ally known that we sympathise with every effort made to relieve the suffering
state of the women of India."

We fear the Maha-Rani would after this be disappointed if she were told
that three weeks later the medical women of Europe and America were ex-
cluded from the International Medical Congress held in London last August,
and that this exclusion was effected by the Queen's private physician, threat-
ening the Congress with the loss of the Queen's name as patron if medical
women were admitted. If this were anything more than an unauthorized ap-
plication of the influence of royalty, it would be desirable for the Queen to re-
member that it will not assist in relieving the suffering state of any of her
Majesty's subjects to prevent their medical attendants from keeping au cou-
rant with every advance in the knowledge of the complex aft of healing, and
that it is not true that a very much less educated practitioner than those who
desired to attend the Congress would be good enough for India. The fact of
the skin of the patient being some shades darker than our own does not, as
some people seem to imagine, simplify alike the physical organization and
the abnormal conditions of the body, and if good medical women are wanted
for India, they must receive as thorough a training as the best medical schools
in England can give to men. The recent successes of the students from the
London School of Medicine for Women in the Honor List of the London Uni-
versity show that in this school, at any rate, the education given is good and
thorough, and we hope her Majesty will in due time have the gratification of
knowing that many medical women who have been trained there are at work
in India and England in relieving the sufferings of her subjects.

I am, Sir, your obedient servant, B.

October 25.

Shall Women Practice Medicine ? 377

to co-education in medicine. We call these ideas superficial,
for they only represent further misconceptions of the mental
attitude of true medical students. The scope of the subjects
studied is so immensely wider than the public can imagine; the
mass of its details so much greater; the intellectual aspect so
different; even the material conditions so changed,' that it is
quite impossible for any one on the outside to judge of the form
of feeling likely to be excited by the actual circumstances within.^
From all this series of misconceptions to which women are
exposed in common with men physicians, and, for many reasons,
more conspicuously than they, it would seem as if members of
the profession should naturally be exempt. "It is an ill bird
that fouls its own nest"; and it seems scarcely credible that any
physician who loves and honors his calling as it deserves, should
dare to pronounce it too coarse or too hardening a pursuit for
women. Whenever this has been done, the argument is neces-
sarily insincere. It is like the outcry of school-boys when their
sisters beg to be allowed to play ball with them. "Go away!
You are a girl! Girls don't play ball!" The school-boy is
usually unable to enforce this brief but effective dictum by dis-
sertations on the difference in the form of the clavicle between
the male and the female, and consequent inferences as to the
necessary inefficiency of girls in the art of pitching and catching.
Grown to manhood, however, he learns to justify his opinions by
formidable weights of erudition. These arguments vary from
age to age, and to-day the fashionable one is drawn from natural
history. By laborious researches into the comparative weight
of the brain, 2 the strength of the muscles, the depth of the respira-
tion, the powers of digestion, the richness of the blood, it is
established that the typical woman, wherever she appears, must
be an inferior animal to the typical man, wherever he may be

» As in the dissection or post-mortem examination of dead bodies.

' Not to interrupt the course of the text, we would here note that schemes
of co-educa.tion which, in some shape, are really essential to the proper pro-
fessional education of women, are always compatible with isolated instruc-
tion on the very few special subjects where the association of young men
and women students might be an embarrassment. But these topics occupy,
after all, a very small part of medicine.

3 It will not be forgotten that the latest tables of BischoflF give the pro-
portions of the brain to the weight of the body as i to 36 for women, i to
37.5 for men.

378 Mary Putnam Jacobi

found. The rapidity with which this abstract conclusion is
applied to such a concrete problem as the capacity of women for
the practice of medicine is amazing. Were the feat performed
by feminine reasoners, it would, no doubt, be cited in proof of
the hasty generalizations of the shallow female intellect. But
we remember the fable of the wolves and the shepherds!

The logical inference from such data as we have quoted, pre-
cisely because they have recently been re-adduced in the argu-
ment about women physicians, can only apply to the relative
positions of men and women in the social organism. We might
infer, if we admit the validity of such researches and the reality
of their statistical value, that the highest, and weightiest, and
greatest amount of effective work must always be performed by
the masculine half of the race. But it by no means follows that
the work of the medical profession lies on this loftiest plane, and,
consequently, the argument in question has nothing to do with
the matter at issue.

Here is the point which, so far, we have hardly ever seen dis-
tinctly appreciated, namely, — that, as the gamut of human intel-
ligence goes, a third-class intellect is quite sufficient to make a
first-class doctor.

This will be clear when it is remembered that by first-class
intellect is meant that of creative genius; by the second, that
of inventive talent ; by the third, the mind possessing the power
of generalizing, adapting, and coordinating what others have
created, discovered, or invented. If we take Newton as an illus-
tration of the first class, Faraday of the second. Trousseau of the
third, it will be evident that the great mass of even our first con-
sulting physicians occupy a lower rank still. On this calculation
the trustworthy but undistinguished family physician, the sheet-
anchor of many homes, must modestly acknowledge that he
holds only the fifth place, — often, indeed, not that!

Surely the natural history argimient, which gives the abstract
estimate of women's capacities as so little lower than those of
man, cannot be used to consign her to the perdition spread out
below this fifth circle! Were it necessary to apply the interpre-
tation, it would be that if all men were Newtons, no woman would
rise higher than Faraday. If the mental development of the
race had paused at the level of Faraday, no woman could claim
more than the erudition of Trousseau, and so on.

Shall Women Practice Medicine? 379

The absurdity and uselessness of such a discussion is fully
paralleled by that of the innumerable discussions which have
been solemnly sustained on this basis. This is our excuse for
pausing to consider it.

Some years ago, Huxley took occasion to say in public: "No
scientific man, well acquainted with the quality and quantity of
the intellectual work actually performed by the average medical
practitioner, could doubt that any vigorous girl could be trained
for the same."

The intellectual work required of physicians is of two kinds.
They nrnst learn an art, and become experimentally skilled in its
various applications. And, during the exercise of this art, they
may collect data which shall contribute to the advancement of
the science upon which the art reposes.

The relation between these two branches of work much
resembles that which exists between the art of musical execution
and the science on which depends musical composition. Now, it
is well known that abilities in these two different departments
exist in no necessary proportion to each other in the same per-
son. Brilliant performers are known whose compositions are
thoroughly mediocre; the most profound musical writers may be
relatively inferior in the technique of figuring. In the con-
servatory at Stuttgart, we have been told that the female pupils
are restricted to the study of execution, and receive no instruc-
tion in the principles of harmony or theoretical music. They
are not expected to compose.

The mental powers involved in the application to concrete
problems of the principles of so great and complex an art as that
of medicine, may easily seem to the outsider to be identical with
those concerned in scientific research. This is not, however, the
case, and therefore objections made to the education of women as
physicians because, without education, they have made no impor-
tant scientific investigations, should fall to the ground by their
own weight. Such objections, if maintained, must rule out of
practice the great majority of successful practical physicians.

Another ' consideration : Persistent innovations are rarely
one-sided. When new claims are made, we may be sure that
they have a foundation in facts. It is so with medicine. Its
modern development renders it more accessible to women.
Thus, the discovery of anaesthetics has thrown open to women

38o Mary Putnam Jacobi

almost the entire field of operative surgery, from which, for-
merly, purely physical disabilities must have excluded them.
This is a branch of medicine capable of being taught with great
precision : and, accordingly, we find that a taste for surgery devel-
ops rapidly among women wherever they can obtain for it the
requisite personal training.^ Again, the immensely greater atten-
tion paid in modern times to the chronic diseases of all the
organs of the body, opens not one but many fields where care,
patience, solicitous observation, detailed attentions, are more
required than the prompt courage supposed to be necessary for
startling emergencies. But, finally, the majority of emergencies
cease to be startling, because, owing to the greater precision of
medical knowledge, they can be far more often foreseen and far
more often coolly analyzed and interpreted.

In a word, whatever tends to perfect the art of medicine, tends
also to render it more susceptible of being taught with positive-
ness, hence more accessible to persons susceptible of training,
but liable to be deficient in originality and initiative. It is the
achievements of masculine genius which, in medicine as in other
departments of life, facilitate the work of women. To what
extent real genius for medical science may develop among women
remains to be seen. The conditions for such development do not
yet exist. Medical training is, in America, everywhere extremely
imperfect, and in regard to women, the imperfection becomes
more obvious on account of the habitual defects in their ordinary
education. They are, as has been already said, deficient in men-
tal initiative; the deficiency is not counteracted, but aggravated
in the great majority of cases by almost all the influences to
which they are subjected from their cradle upward. Few agree
with Mr. Morley "that there is probably nothing which woiild
lead to so rapid and marked an improvement in the world as a
large increase of the number of women in it with the will and ca-
pacity to master Newton as thoroughly as she (the Marquise du
Chatelet) did." ^ Everything in ordinary life is opposed to the
thorough mastery of anything by women. The study of medi-
cine necessitates, in this respect, an entirely new departure.

» Dr. Van de Warker says that we are yet to see the female ovariotomist
We know of at least seven ovariotomies performed by women, of which five
were successful.

* Life of Voltaire, p. lOO.

Shall Women Practice Medicine? 381

Experience shows that this is not difficult to effect wherever
women students are submitted to an authoritive and impos-
ing discipHne — as in the European universities to which they
have been admitted. But the self-enforcement of such a disci-
pline is necessarily rare. The capacity of women for purely
mental initiative is often at present encroached upon by the
severe struggle with practical and pecuniary necessities to which
so many of them are subjected. The self-denial, energy and
pluck, ingenuity and perseverance of hundreds of women stu-
dents would make, if published, an heroic record. Through
poverty, opposition, ill health, often with insufficient daily food,
— often compelled to work, in addition to their studies, to earn
their daily expenses, — these women struggle on uncomplaining.
They are obscure, unknown — often remain so; often fail from
attempting the impossible, yet, oftener than could be imagined,
succeed at least in rising to the standard which is established for
them. It remains, perhaps, for another generation to do more.

From what has been just said we certainly would not have it
inferred that we argue the necessity of accepting women as an
inferior grade of practitioners, to be tolerated in trifling ail-
ments and to be set aside in serious illness. Our argument is
simply that, at the present stage of medical development, the
mental powers exercised in the treatment of the most serious
illness lie, both as to quality and quantity, within the range of
the theoretical estimate now generally made of the intelligence of
women. These powers are apt to seem more extensive than they
are, because, from the nature of the case, they usually come into
play in the presence of persons unqualified to criticise them. So
long, however, as the physician confines himself to the application
of the rules of diagnosis and of treatment contained in his art,
his work, however judiciously and skillfully performed, must, as
an intellectual performance, be ranked as second-rate. To say,
therefore, that the intellectual capacities of women are only
second-rate by no means excludes them from the most responsible
duties of practical medicine.

Again, chased from the first assumption, the determined pre-
judice finds refuge in a second, and we are confronted by the
assertion that women physicians must be lacking in the normal
qualities of self-reliance, steadiness of nerve, self-control, etc.
Here again, we believe, the fallacy lies, first, in taking for

382 Mary Putnam Jacobi

standards of comparison women quite untrained for the work;
second, in misunderstanding the effect of knowledge in dis-
sipating the alarms principally excited by mysteries. To be firm,
self-reliant, and steady in dealing with the friends of the patient
is no harder for a woman involved in medical than in other
responsibilities. To assume the burden of such responsibilities
in regard to the patient requires the ability to say : " I know the
condition of this patient at least as well as any other person to
whose opinion I could have access. I am also acquainted with
the nature and extent of the resources which the art of medicine
at present possesses for such a case. It is my business to apply
those resources with all possible care and diligence, and to await
the result."

This is not the frantic "wrestling for the life of the patient"
which figures in popular imagination, but it is the sober truth.
It is not the language of an excitable person, bewildered in a
dramatic situation, but that of a well-balanced intelligence,
thoroughly trained for the work which it has undertaken.

If a really first-class intellect be often rather out of place in
the practice of medicine, a high degree of vitality, of organic
vigor, is certainly needed. Now, it is not usually recognized to
what an extent the organic vigor of women is naturally destined
to be increased by child-bearing. The prevalent American notion
is that maternity is the signal for an inevitable collapse of all
mental and physical powers. The reverse is certainly intended
in the scheme of Nature. The key-note to the difficulties of the
position of women in regard to the achievement of distinction in
any form of work, lies in the fact that the degree of their physi-
cal, and probably, therefore, of their mental, development before
child-bearing is always rudimentary, relative to that attainable
after it; while, nevertheless, the risks, duties, and social conse-
quences of maternity tend to so completely absorb this increased
vitality that none remains over to be expended in external work.

It is foolish to overlook or to dispute this fundamental fact.
But it is equally useless to insist upon it, as in itself sufficient
to decide the social destinies of woman.

The "social consequences of maternity " vary indefinitely with
the social class. Immense numbers of women are compelled, by
the most inflexible economic conditions, to work as hard, in fac-
tories or elsewhere, after marriage as before. "If," says Simon,

Shall Women Practice Medicine ? 383

"the family can only be supported by three francs, and the man
can only earn two, there is no alternative but for the woman to
labor to secure the remaining franc. ' ' The range of non-domestic
industry rises, without changing its essential nature, from the
level of the European factory operative to that of the American
farmer, where the share of the married woman in the conduct of
the farm is considerable. Marriage cannot be said to withdraw
from non-domestic industry the majority of women, but only to
increase their burdens, and set them to work at a disadvantage.

On the other hand, in another immense class, or, rather, series
of classes, the amount of work performed by women in the dis-
charge of household duties is fully equivalent to the amount of
non-domestic industry performed previous to marriage. The dif-
ference lies in the arrangement; and it is claimed that this facil-
itates the duties of maternity, and care of children, while any
non-domestic labor must disastrously antagonize these.

Finally, for much the smallest, but also the most influential
because the most distinctly articulate class, marriage means, or is
expected to mean for the woman, liberation from any definite in-
dustry. The work of *he household is performed by servants;
and the funds are entirely supplied by the external work of the
husband. This, indeed, in theory; in fact, in all dense social
communities, and there especially in professional circles, the wife
is often expected to contribute an essential quota toward the
maintenance of the household, by means of an inherited fortune
or of the dowry received from her father. As it is evident that
physicians must come, not from the so-called laboring classes, but
from those where the married woman either works in the house or
does no real work at all, the practice of medicine by married
women becomes involved in the following problem: To so ar-
range, at least certain forms of non-domestic labor, that even a
married woman should be enabled to engage in them if her taste
so inclined, either in preference to the domestic work which she
would otherwise be compelled to perform as a substitute for a
dowry, without which she might be compelled to remain unmar-
ried, or as a substitute for an elegant leisure, which, to an ener-
getic temperament, is often a refined torment.

On the theory that work is a mere personal hardship, to be
evaded whenever possible, to be sought only for an indispen-
sable pecuniary return, and always, even in our democratic coun-

384 Mary Putnam Jacobi

try, implying for women a faint social disgrace, there is not
likely to be any enthusiastic support among married women of
professional or other work to be performed by any of their
number. This is why the frequent denunciation of such work
by fashionable women is always open to suspicion. On the
broader theory, that the amount of work to be done in the world
implies a collective fund of activity, to which all human beings
may lawfully desire to contribute, each freely choosing such por-
tions of it as are most suited to his or her special capacities, the
matter assumes a different aspect. Whatever real difficulties
may lie in the way, the one at least should disappear which is cre-
ated by the half-avowed dictum: "No woman has any right to '
work who can get a man to support her."

This excursion into the general considerations about the work
of women is necessary in order to understand the real force of
much of the more obscure opposition which exists to women
physicians. As has already been said, the profession of medi-
cine cannot be taken up and laid down again, like the lower
positions in industrial occupations, or even like the profession of
teaching. It must be adopted, if at all, for a life-time. Its ripest
fruits cannot be gathered until a ripe age, long past that most
suitable for marriage. On this account, and because the women
who are most likely to succeed in medicine have often also
marked capacities for success in marriage, and because their
ability to perform such work as that involved in the practice of
medicine, and demanding high organic vigor, tends to be in-
creased after marriage and the possession of children, — for all
these reasons, it is felt that the question of women in medicine
touches upon the ground not covered by their pre-marital work
elsewhere. To the question, "Is it possible for married women
to practice medicine?" experience might already be supposed to
return an answer. A very considerable number of women now
practicing have either married after entering upon practice, or
were already married when they began. To what extent either
their households or their practice may have suffered by the com-
bination, it is almost impossible to ascertain by the most care-
fully prepared tables of statistics. It is not yet even certain
whether the combination influences the size of the family. As
far as can be judged, this remains at the measure most habitual
in the families of professional men. Since this paper is intended

Shall Women Practice Medicine ? 385

to discuss rather theories than facts, it is worth while to outline
a tjrpical case, such as is not unfrequently realized :

A healthy girl of eighteen, with an ultimate view to the study
of medicine, enters upon a university course, and, at the age of
twenty-two, begins medical study. She is ready for practice at
twenty-seven, marries at the same time or a year later. Her chil-
dren are born during the first years of marriage, thus also during
the first years of practice, and before this has become exorbitant
in its demands. The medical work grows gradually, in about the
same proportion as imperative family cares grow lighter. The
non-imperative duties — the sewing, cooking, dusting, even visit-
ing— are susceptible of such varied modifications of arrangement
as it would be trivial to discuss in these pages. So great is the
division of labor in medical work that it is indeed rather the
minority of physicians who can consider themselves fortunate in
being "overwhelmed" with practice. In respect to the quantity
of work performed by women, the same rule may be applied as
has been laid down for the admissible proportion for the laboring
classes — namely, about one-third of that performed by men of
the same grade of success and ability. This fact need not impair
the quality of the work. Professional work, which must remain
a form of personal or hand labor, cannot be measured by com-
mercial estimates. Beyond a certain point, increase of its quan-
tity tends to impair rather than improve its quality. A mass of
work sufificient to involve serious drafts on physical strength
must, in medicine as elsewhere, put nearly all women at a disad-
vantage. But the handling of such large masses is neither neces-
sary nor desirable for any other than pecuniary reasons, and
these, both for physicians and for women in general, may be left
in the background. To neither is the attainment of a fortune
important; for the majority of both it is impossible. This must
always remain true of physicians; whether it always remain as
true of women as it seems to be at present, depends upon the
extent to which they may rise from the bottom of the industrial
scale, where they swarm at present, to the top — a question which,
however interesting, does not concern our present subject.

The character of medical work, in its external and obvious
aspect, — ^that of examining, watching, and prescribing for sick
people, — suggests a degree of adaptability to the exigencies of
domestic life which especially commends it to women. This

386 Mary Putnam Jacobi

is one reason why so many choose it, in preference to other
occupations. In these reasons for a choice, there lurks, however,
a danger, which it is well to distinctly recognize. It is that of
overlooking the importance and extent of that part of the phy-
sician's work which is performed outside of the consulting room,
and away from the patient's bedside. In the mind of the true
physician, this bears about the same proportion to the work of
practical intercourse with the sick, as for the pianist exists
between his hours of preparation and practice and those devoted
to public concerts or teaching. It is true that this ideal is
rarely maintained; but it exists, and tends to become more and
more frequently realized during the progressive development of
modern medicine. Now, it is in regard to this ideal that the
present generation of women physicians are more liable to be
deficient than in regard to the energy or solicitude of their at-
tention to patients. It involves some vigor of mental initiative,
and, as has been already noticed, the same women who will re-
spond admirably to training, to direction, or to the pressure
of practical necessities are apt to be unexpectedly deficient
in this.

Since it is only the gradual progress in mental culture which
has, for men, aroused mental initiative in the field of medicine,
we may reasonably hope that the same process will have the
same result for women also. Already a sufficient number of
feminine examples exist to prove that this is quite possible.
There is a gradual, but undoubted, increase in the capacity for
mental initiative on the part of women in general. Those who
study medicine must first share in the general movement; after-
ward, must become more energetically animated than at present
by the intellectual impulses of modern medical thought.

We have already asserted that the idea that culture is a
means, not only of training, but of developing force, is not gen-
erally accepted among current popular notions. It is, however,
fully recognized by authorities, and we need, therefore, spend no
time in defending it. Our commentary upon the practice of medi-
cine by women does not profess to be very systematic; it evades
argument of rights, statistics, and historical statements, partly
because these have already been made in an admirable manner, '

' See "Study and Practice of Medicine by Women," Dr. J. R. Chad wick,
"International Review"; "Study of Medicine by Woman, " Miss Jex-Blake,

Shall Women Practice Medicine ? 387

partly because, in our opinion, sufficient data do not yet exist for
statistical conclusions. The whole number of women at present
practicing medicine is small; thus, only about four hundred
can be reckoned in America; only nineteen are registered in
Great Britain. From this small number, with the imperfect
preparation and surroundings of so many among them, to at-
tempt to draw any inferences as to the theoretical grade of
capacity of women for medicine is absurd. Still more absurd
to attempt to deduce general conclusions in regard to the mental
capacity of women in general — its development, progress, or
unimprovability.

Deferring exact researches, our modest intention is simply to
attack the floating mass of vague ideas, prejudices, preconcep-
tions, and misconceptions which, in this as in so many other
matters, really decides the practical action of the community.
Drawing to the close of our brief discussion, we are aware that
it will seem to leave several questions not only unsettled, but
untouched. If there are so few women who, after all, come for-
ward to study medicine, why is it necessary to disturb oneself,
or, in the slightest degree, society, about them?

We answer: It is scarecely forty years since the first woman
physician graduated in America; not more than thirty since
the first school was opened to them; not more than fifteen
since an5rwhere in the world, they could obtain a university
education, and from this, in many/parts of the world, they are
still excluded. It is not, therefore, surprising that the number
of women in medicine is still small.

Further the demands of these few nave involved a sacred
question — that of justice. It is this little band of women phy-
sicians who most conspicuously represent the modern claims of
women to share in the general intellectual development of the
race. Their demands have not only been refused, but refused

"Fortnightly," March, 1875; 'Reply to Bischoff on the Admission of Women
to the School of Medicine at Zurich," Prof. Herman; Speech of Dr. Henry
Bowditch on the Admission of Women to the Massachusetts State Medical
Society; Report of Committee on Admission of Women to Harvard Medical
School, Chairman Prof. Alex. Agassiz; "The College Story," Prof. Rachel
Bodly; "Practice of Medicine by Women in the United States," Drs. E. &
A. Pope, and G. L. Call; "Early Practice of Medicine by Women," Prof. Bol-
ton, "Journal of Science," ]annary, 1881; "Women in Medicine," "Michigan
Exchange," Lydia Welch.

388 Mary Putnam Jacobi

with contumely, and themselves treated with the tyrannical con-
tempt which Prussians and Anglo-Saxons habitually reserve for
those who urge a claim without the physical force to secure it.
This is the first reason why the question, insignificant as regards
nvimber, has a real social importance.

The question at issue does not concern the training of scien-
tists or the development of original genius, but the training for
a practical work of persons who have demonstrated at least
very many of the abilities requisite for it. In this they have
put themselves, so far as regards native capacity, on a level with
the great majority of the members of the medical profession. It
is possible, if not probable, that they have shown themselves
less able to dispense with thorough training than their masculine
colleagues, less to compensate its deficiencies by self-imposed
efforts. No practical inference can be drawn from this other
than one which applies to the entire relations of the state to
medical education, viz., that every practitioner should be much
more closely supervised. Efficiency should be more seriously
and more often tested, and the public far better protected than
it is at present from the incompetence of both male and female
practitioners. It is the height of folly to trust to American
ingenuity and quickness to escape the consequences of imperfect
knowledge. If it be desirable to establish a rigorous discipline
for women physicians, it is no less important to do it for men,
so that, practically, the distinction disappears.

In regard to any unpleasant modification of female character,
likely to result from medical or other superior education, it cannot
be too frequently noted that nothing further is proposed than to
make room for the varying types of women which actually exist.
Mr. Bagehot declares that an unvarying type of character is
characteristic of a barbarian community, because essential to its
safety, and is, therefore, enforced by all penalties, even to that
of death. Only civilization is flexible enough, and stands on a
broad enough basis, to permit internal variations. Surely women
may share sufficiently in civilization to be allowed, without social
disgrace, to exhibit such variety? The taste for medicine, when
profound and genuine, is certainly peculiar enough to establish
a decided variation on the most conventional type of women.
But many other tastes do the same; and choice remains
free.

Shall Women Practice Medicine ? 389

" The crane, I said, may chatter with the crane.
The dove mate with the dove, but I
An eagle, clang an eagle in my sphere!"

A final reason to be considered in regard to the professional
work of women, and its possible continuance after marriage, lies
in the re-arrangement of domestic work which has gradually been
brought about by the growth of modem industries. As every
woman knows, these are built up of tasks which have been with-
drawn, one by one, from the control of the household and of its
mistress, and have been combined, perfected, amplified to whole-
sale and often gigantic proportions. The process necessarily liber-
ates the energies of the woman formerly absorbed by these same
necessary tasks of preparing food and clothing. The process
is still going on, and is constantly simplifying the material
mechanism of household existence.

The "invasion of foreign spheres," for which women are so
often reproached, is only the natural result of the double pressure
of an economic and of a psychological necessity. It is always
necessary that human beings be occupied; if driven from one
thing they must take up another; if all employment be taken
away from them, they must at least pretend to be busy. On the
other hand, it is not only obviously desirable that unmarried
women find as many avenues for employment as possible, but
the possibility of contributing toward the support of a family
may decide, for many women, the alternative of marriage or celi-
bacy. The traditional method of effecting such contribution is
by means of a dowry; in many cases, it both has been and is the
only possible way, since neither the strength not the ability of the
woman would enable her to engage in any non-domestic work,
and yet do justice to her children and household. Any woman,
however, who is possessed of the requisite physical and mental
strength should be allowed, at her choice, to contribute the
profitable work for which she has been trained, in lieu of a dowry
which she may very easily not happen to possess, or in lieu of cer-
tain domestic labor which she would otherwise be compelled to
perform on account of the narrow income of her husband. Is the
sentiment of marriage endangered by the habits of pecuniary
self-reliance and independence which should tend to free mar-
riage from its burdensome aspect as a "career," and an indis-
pensable means of livelihood ?

390 Mary Putnam Jacobi

All professional work constitutes a form of personal service,
and, as such, is much better suited to the prevailing instincts of
women than industrial or commercial pursuits. The adaptation
on this side is indeed so great as to constitute a danger; for it
should never be permitted to obscure — and, in fact, it sometimes
does — the cardinal question of capacity. We have said what we
think there is for the present to say, in regard to the proof of such
capacity in women. Here, in closing, we only wish to refer to its
desirableness as a means of stimulating to better efficiency
much existing feminine occupation. When room is made so near
the top as is the high, difficult, and responsible work of practical
medicine, the lower ranks may thin out by promotion. The
pitiful overcrowding of the meanest employments by the huddling
together of all grades of capacity, from that of the raw Irish girl
to that of the reduced gentlewoman, might cease when fair play
was once allowed for superior energies.

Have we not had enough of the dictum, "Women cannot do
men's work?" In reality, some woman can do the easy work of
some men ; others can do the more difficult work of more power-
ful men; finally, there are some men whose work, either for mass
or quality, has so far not been equaled by the achievements of
any woman. And this is all there is to say about it. It is desir-
able that every woman remain as inferior to her own husband as
may be feasible and convenient; it is for that purpose she mar-
ries him, or should do so. But the generalization of this relative
inferiority to the comparative capacities of all men and all
women, in regard to every work that both undertake, is a most
injurious absurdity.

When we shall be rid of the injustice, the unfairness, the
monstrous pretensions, and arrogant argtunent with which
the subject of the admission of women to medicine has hitherto
been so largely treated; when the mass of women students can
obtain the same education and women physicians the same
facilities that men do, a sound theoretical conclusion may then
be reached, if required. But by that time the practical conclu-
sion will probably have established itself, and people will cease
to interest themselves in dissertations on the true theory of
un fait accompli.

AN ADDRESS DELIVERED AT THE COMMENCEMENT

OF THE WOMAN'S MEDICAL COLLEGE, OP THE

N. Y. INFIRMARY, MAY 30, 1883. -"

Ladies of the Graduating Class : — When you first honored
me with an invitation, I dedined, and for a reason well known to
you. I think it extremely difficult to find a theme that shall be
interesting at once to medical students, and to these assembled
friends, who, though much interested in certain students, can be
expected to take but little interest in medicine.

Were the devising of graduation exercises entrusted to me, I
should not hesitate to borrow from the ceremonies of the antique
Eleusinian mysteries, or from those of the mediaeval Rosi crucians.
For however much the light of common day and of common-
sense may have been let in upon the art of medicine, it still re-
mains a mystery, a sacred mystery, to the uninitiated; that is, to
all who have not been submitted to a prescribed discipline.

If, however, I should seek a ceremonial of graduation appro-
priate, not to the mysterious and difficult nature of the studies
you have pursued, but to the arduous personal responsibilities
you are about to assume, I might find it in the vigils prescribed to
the candidates for knighthood in the Middle Ages. These were
required to spend a night in fasting and prayer in a solitary
chapel, watching the armor and the scabbarded sword they had
not yet been permitted to unsheath. There are so many spiritual
resemblances between the duties of an energetic physician and
those of a well-armed knight.

" Bound for the wide world past the river,
There to put away all wrong," —

that we should not be far amiss if we imitated these solemn

vigils of his initiation. And were we habituated to the accurate

' Reprinted from the Archives of Medicine, 1883, Editorial Department.

391

392 Mary Putnam Jacobi

sym llsm of a more imaginative age than our own, we should at
least take care that the garlands which were offered to you in con-
gratulation, were composed, not of roses, but of thorns. For it is
thorns, and not roses, which fitly symbolize the career upon
which you have now chosen to enter.

No symbolic or mysterious ritual, however, is likely to be
either revived or invented for the graduation of students in medi-
cal schools in modern New York. There is, however, a wide-
spread feeling among the Faculty of this School, that the exer-
cises of graduation should be exclusively medical in character;
that the examinations should be entirely, or in part, conducted in
public, before a medical audience competent to judge of their
excellence; that the students should defend their theses; should
give evidence of practical conversance with the duties of their
profession, by examinations at the bedside of patients. The
graduating exercises, in a word, should all be performed by the
graduates, and not before them, by some one else. Thus only
they acquire real significance and importance. Thus only, I may
add, could they be affiliated to the customs of the great European
universities, which, in this, as in other matters, must remain
our permanent models. These considerations carry so much
weight, that I am happy to believe it not impossible that this may
be the last public commencement, in the popular sense, ever held
by our School. In that case, it would be the last occasion on
which the graduates and their non-medical friends could con-
sider together some of the non-medical aspects of their profes-
sional career.

Now, in this connection, the topic which most frequently
suggests itself at our graduation exercises, is that of the sex
of the graduates. Indeed, you are liable to be so much and
so frequently reminded that you are women physicians, that
you are almost liable to forget that you are, first of all, physi-
cians.

As a rule, I have always advised you to reverse this order;
to so saturate and permeate your consciousness with the feeling
for medicine, that you would entirely forget that public opinion
continued to assign you to a special and, on the whole, inferior
class of workers in medicine. Still more have I advised you
to forget that, in attempting to become physicians at all, you and
— far more than you — your predecessors, have in any way braved

Commencement Address 393

public opinion. If it be a new place into which you have
entered, it is incumbent upon you to acclimate yourselves as
quickly and thoroughly as possible to its atmosphere, and not
keep dawdling on the threshold to forever remind yourselves
and every one else that you have only just come in. Recently
emancipated people are always bores, until they themselves have
forgotten all about their emancipation. But those, whose souls
are really bom free, easily regard the trammels imposed upon
them by convention or circumstance as trifling accidents which
must necessarily be set aside. They do not dream of glorifying
themselves because a barrier has fallen down ; if the barrier be an
injustice, they know that sooner or later it must fall, and once
out of their way they spend no further thought upon it.

There is certainly enough, and far more than enough, in medi-
cine to interest and absorb you, without diverting your attention
to questions of your social status, and if you do not find the facts
of medicine more interesting than any other facts, you are not fit
to be physicians. There are, however, occasions on which it is
proper to consider the fact that you still constitute, to a consider-
able extent, a class. You have, therefore, a certain class of inter-
ests, and it is important that you should neither overlook these,
nor belittle their real importance. For if medicine, or rather,
biological studies in health and disease, be to us the most inter-
esting of all subjects, we must admit that after this, the over-
throw of social prejudices, tyrannies, and monopolies is, perhaps,
the next most interesting theme that could engage the attention
of any one. And of all monopolies, what has ever been more
odious than that which has restricted to one half of the human
race the advantages of education and the facilities of increased
life which that confers, while the other half of humanity has been
forcibly excluded from both ?

It is true that this monopoly, like all other class monopolies
which ever existed, could be defended at first as a simple ex-
pression of a natural order of things, and afterward by all the
force of the association of ideas which this original order en-
gendered. Yet there never was a time when the monopoly
was not self-contradictory and injurious. There was no business
reason why women should not have been educated in ancient
Athens, for there, education was only designed for refining social
intercourse. But, as every one knows, the more respectable and

394 Mary Putnam Jacobi

high-toned the woman, the less was she allowed to be taught.
There was no family reason why the celibate nuns of the Middle
Ages should not have shared in the early movement toward learn-
ing which began in the monasteries; but it is certain that they
were not so allowed. There is no economic reason why in
modern England, with its thronged population of unmarried
women dependent on their own exertions, the slightest opposition
should have been offered to the opening of a new profession to
woman as a means of livelihood. But in no part of the civilized
world, not even in America, has opposition to women students
and practitioners of medicine, been so bitter, so brutal, so densely
organized, so versatile in its resources, so multiple in its hypocrisy,
as in England.

The more we reflect upon this opposition, the more incom-
prehensible does it appear. Let it be admitted that, for one reason
or another, the mass of women had shown, or rather had ap-
peared to have shown, indifference to learning and to the higher
forms of work.- Should we not have supposed that every class
in the community would have hailed with the liveliest satis-
faction the first manifestation of such interest on the part of
women? Granted that facts seem to justify, at least a provi-
sional scepticism, in regard to the ability of women to profit by a
professional education in abstruse subjects, why should any one
have hesitated to offer the fullest opportunities for the develop-
ment of their powers and the decision of their individual capacity ?
The mass of argument, sarcasm, ridicule, invective, and down-
right calumny which has been poured out upon the heads of the
women who, for the last thirty years, have been trying to study
medicine, can only be explained by the constant tendency of all
monopolies to strengthen themselves by injustice, as soon as they
feel that their exclusive privileges are menaced. The argument
most frequently brought to the front is, that the presence of
women must lower the prestige of any institution to which
they were admitted as co-workers or fellow-students with men.
When the London University was debating the question of open-
ing its degrees to women, the medical journals received many let-
ters from former graduates of its medical school, solemnly protest-
ing that such an admission would be a violation of their vested
rights, — since it must necessarily lower the value of their
diplomas long ago earned and paid for. The same considera-

Commencement Address 395

tions have dominated the action of the Harvard Medical School
in this country. In this city a few weeks ago, when a young
lady physician had successfully passed a competitive examination
for position as interne in one of our hospitals, one of the exam-
iners remarked that he should be opposed to her admission for
this reason: there would be no difficulty so long as she held the
junior position; but when, in ordinary course of promotion, she
should advance to the higher grades, it was to be feared that new
candidates of value would not present themselves for the ensuing
vacancy, when they heard that, if successful, they must serve
under a woman as a superior officer. Now it happened that at
the last examination which had been held at this hospital, the re-
sults were so unsatisfactory that all the candidates were rejected.
Had this happened after the nomination of the lady in question,
— for she was appointed, — how easy it would have been to infer
that it was her presence in the hospital which had deterred suit-
able candidates from presenting themselves !

There have been but three other occasions on which women
have attempted to compete for positions in New York hospitals.
On the first, the candidate passed a successful examination, and
was admitted without further ado. On the second occasion,
when a vacancy was open at Charity Hospital, the woman candi-
date was acknowledged to have beaten her competitors, but was
then refused the place for which she had worked so hard. On
the third occasion, a yoimg lady attempted to come up for an
examination which was announced for vacancies in the staff of
assistants at the female insane asylum at Blackwell's Island. The
Commissioners of Charity promised that 'she should be consid-
ered eligible; but one of the medical examiners deliberately mis-
informed her as to the date of the examination, so that she could
not present herself. The resident superintendent, temporarily in
charge, further declared that he should in any case decline to be
governed by the results of a competitive examination; that he
should appoint whom he chose, and he certainly should not
choose a woman.

Now Dr. Tuke, the famous English alienist, who had been
studying the organization of insane asylums all over the United
States, has expressly declared that the best conditions were
invariably found where the female patients of the asylum were
under the charge of a resident female physician. Similar testi-

396 Mary Putnam Jacobi

mony comes from every asylum where women physicians have
been installed. Nowhere is it more desirable that they should
obtain a footing than in the vast bedlams of our city almshouses
for the pauper insane. But because a handful of persons in
charge happen to dislike what they consider an innovation, all
attempts to secure competent female assistants on the islands
have so far failed.

Hospitals, as well as universities, belong, of right, to the com-
munities which support them. Nothing can be more absurd than
the asumption, almost universally made, that either the trustees
who administer such public institutions or, in the case of hos-
pitals, the physicians who visit in them, have the right to mono-
polize their privileges to the exclusion of any duly qualified
citizens. In regard to universities and professional schools, it is
well known that this assimiption is far from being tacit. Appli-
cations for admission have been made by women over and over
again, and refused as calmly as if these public institutions were
pieces of private property, upon which intrusion was an imperti-
nence. In regard to hospitals, the question has been much less
sharply defined, because as yet few candidates have presented
themselves. Few women have had the courage to undergo a
long and expensive preparation for an examination, to which,
after all, they might at least be pronounced ineligible. No woman
has even ventured to apply for a position in the Woman's Hos-
pital, where, if anywhere, it might be presumed that a woman
physician should be entitled to a place. It has been stated, I
know not on what authority, that in this particular hospital the
Board of Lady Managers would peremptorily oppose the admis-
sion of women internes, even if they had conquered their place
by competitive examination, and had overcome the prejudices of
the medical staff. It is very certain that not a member of this
Board has ever taken the slightest step toward securing the
services of a physician of their own sex for the women under
their care, nor toward throwing open the advantages of this
hospital to the women physicians who might worthily profit by
them.

This practical monopoly of the vast clinical opportunities con-
tained in the hospitals, dispensaries, and city institutions of New
York, can not, however, be made a matter of serious complaint
until competent women candidates shall have come forward in

Commencement Address 397

greater numbers and with more determination to demand their
share of this public property. When the demand is once made,
it cannot but make itself heard. When at least half of the
hospital population are women, and sometimes a third are chil-
dren ; when female nurses are being trained in large and increas-
ing numbers within the hospital wards, it is absurd to allege that
from motives of either delicacy or convenience, female physi-
cians must be excluded. If, in certain hospitals, the existing
arrangements are such that a woman interne could not perform
all the duties, then the existing arrangements should be modified
whenever a woman candidate shall have demonstrated her intrin-
sic fitness for the place at a competitive examination. There is no
good reason why, in such a case, the female wards of the hospital
should not be assigned to the woman interne, the male wards to
her masculine coadjutor.

The appointment of women on the staff of visiting physi-
cians to a general hospital is a question that has not yet
come up.

This subject of hospital appointments well illustrates the close
solidarity of interests which exists between women physicians.
It will not do for you to forget this, and to imagine that when
you have once secured your several diplomas all your class
work ends. It will not do to imagine that devotion to your own
individual interests and advancement will suffice to secure even
that. You must combine to remove the difficulties which stand
in your way as a class, and to which the fortunes of any indi-
vidual among you are always liable to succtmib. The habitual
exclusion of women from fit opportunities for preparation or
exertion, engenders an habitually low tone of confidence in their
abilities, which constantly interferes to prevent any given woman
from demonstrating her abilities. We have not yet reached the
time when it will be considered as natural for a family to employ
a woman physician as a man; or where the profession of medi-
cine will be evenly distributed between men and women as is
now the profession of teaching. To bring about this state of
things requires much effort, individual and collective, persistent,
patient, far-sighted, indomitable. The problem involves ques-
tions of rights, but is by no means only a question of rights.
An inequality must be rectified, and in the teeth of much oppo-
sition ; but the most delicate part of the task consists in actually

398 Mary Putnam Jacobi

raising to an equality the class which hitherto has been really
inferior.

You may contribute to this great work in two ways. In the
first place, you should be continually exerting yourselves to
increase the educational advantages of the school of which you
are alumnae, and also to extend the opportunities for under-
graduate education elsewhere. It is strange how little our gradu-
ates have hitherto exerted themselves in this respect. The
seventy-five whom we have by this time sent forth from among
us, could, if solidly united in purpose, immensely increase the
educational facilities of those who come after them. But it is a
short-sighted policy to imagine that the affairs of the school
no longer concern you because you will never be obliged to
re-enter its undergraduate course. On the contrary, who is to
look after them if not you ? Why should outsiders, from motives
of pure philanthropy, busy themselves with collecting support for
institutions and enterprises which should by' this time be man-
aged by the collective efforts of the college graduates ? There is
another kind of educational effort which it is most important for
you to make : I mean the continued education of yourselves. It
is a commonplace of commencement addresses to remind you that
your education is only just begun; that you must continue to
study and improve, and so on. I am not speaking however in
this general sense, but with reference to a certain peculiarity
whose importance has probably not yet impressed you. This is,
the remarkable contrast apt to be shown between the energy
which women will manifest in obeying authoritative orders
for study, and the lack of energy they show in independent
initiative. Experience in medical, as in other tuition, has abun-
dantly proved that in every class there is always a fair proportion
perfectly capable of learning all that can be taught them. When
such students are found insufficiently prepared on any sub-
ject, we may justly lay the blame to some defect in the method of
teaching. And at present, the method in vogue of teaching the
medical sciences is so defective that it is not surprising so many
students remain so far below their real capacity of attainment.
But under whatever guidance a student is instructed, there
comes a time in which he must become his own guide; in which
further knowledge must be obtained in obedience to his own con-
sciousness of its interest and necessity; in which further dis-

Commencement Address 399

cipline must be self-imposed. And it is precisely here that
women students are apt to fail, to stand still, to abandon all defi-
nite intellectual purpose, and begin to drift like rudderless ships.
When we consider the often enormous efforts and sacrifices
made by women to secure opportunities for study and to work
their way toward a diploma, it is nothing less than astounding to
notice the intellectual apathy into which so many sink, as soon
as the coveted parchment is secured.

Comment on this circumstance may perhaps be deemed in-
appropriate on this occasion, and a discouraging endorsement of a
widespread reproach that has long enough been made to women :

"Yea," said Cyril: "they learn the old things as well as we.
But when did women ever yet invent? "

I have, however, a word to add in at least partial explanation.
Lack of intellectual initiative is by no means confined to women ;
it is, in fact, the average condition of the human race. Few, and
far between, are the minds sufficiently vitalized, self-reliant, and
self-poised, to be able to disengage themselves from hand-to-
mouth, every-day necessities and preoccupations, and to pursue
an ideal inquiry for its own sake, or for the solitary pleasure of
rounding off and completing their stock of knowledge on any
given subject. The great mass of intellectual work that is done
in the world, is still done in obedience to order; more remote,
less direct than that which lays down the curriculum for under-
graduate studies, but still an order which emanates from some su-
perior mind, or from the collective intellectual force of the com-
munity. This work is being incessantly stimulated by a complex
machinery of societies, publications, prizes, places, reputations,
innumerable rewards of most varying character, but all con-
sciously or unconsciously directed toward fostering the mental
activity of those who would not work without them.

Now, to the extent to which women continue to isolate them-
selves, or to submit to enforced isolation from this vast cur-
rent of intellectual life, it is inevitable that their own must become
apathetic. All impulse to energy finally comes from without,
as all life depends upon the sun. Before, therefore, much stress
can be laid on the reproach of lack of initiative in women, it
behooves us to consider whether the position in which they now
are is one in which mental initiative has ever been developed on
a large scale among men. Their position is colonial; and every

400 Mary Putnam Jacobi

one knows the singular combination of mental inactivity with in-
tense practical energy, which peculiarly characterizes colonial
life.

The disingenuous hostility to women physicians, which has
marked every step in our thirty years' struggle, — we may justly
call it a Thirty Years' War, — has much abated in regard to the
elementary question, whether women should receive legal author-
ity to attend such sick persons as chose to consult them. For-
tunately for us, the habit of consulting with reputable women
practitioners has been established, some time before the present
concession to consultations with homoeopaths could have robbed
consultations with women of all significance. But the effort to
exclude women from the full privileges of the profession still con-
tinues; is manifested in such struggles as that which convulsed
the Massachusetts Medical Society at its centennial; in such
resolutions as that which excluded women from the International
Congress at London; in the annual debates over their admis-
sions to the British Medical Association; and in the discussions,
of various degrees of acrimony, which are excited by the applica-
tion of a woman candidate to any medical society where a woman
has not yet been admitted.

To overcome all this opposition it is necessary not only to
make persistent application to these same societies, but to
engage resolutely, and without the aid of their stimulus, in the
same work in which they are engaged. Our English colleague,
Dr. Frances Hoggan, has always been excluded from the Patho-
logical Society of London. But the original work in histological
investigation that she has pursued with her husband in their
laboratory at home, has received deserved recognition in the
leading journals of France, Germany, and even England. It is
the old story of the bricks, to be made without straw; of the
shield to be hammered by the Antwerp artificer, without tools.
The task is difficult, extremely difficult, but it is by no means im-
possible. The important thing is to recognize the necessity for
constant definite mental work in definite directions; and the con-
ditions under which this can be performed. This may not always
seem to have any bearing on the practical work you may be at the
time engaged in. But you may be very sure that if you attempt
nothing but what seems at the time absolutely necessary, you will
always remain wofully below the measure of the needful. In

Commencement Address 401

intellectual life it is not altogether a paradox to say, "Give us
the luxuries, and we will dispense with the necessaries."

Evidence of a free, self-sustained, self-reliant intellectual
activity is justly demanded as proof that a physician is capable of
exercising the independent judgment which is absolutely neces-
sary for the handling of the simplest case of disease. You cannot
treat the sick by means of folios of precepts, the most precise and
accurate that were ever devised. And to be able to modify the
precepts which you have been taught as a basis for your self-
instruction, your minds must have been trained to inquiry, to
independent pursuit of knowledge, to the grouping of facts, to the
summing of evidence, to the original observation and suggestion
which a free mind pursues as its natural and inevitable occupa-
tion. Do not, therefore, continue to justify the old assertion that
the only free choice a woman ever really cares to exercise is that of
choosing her own master. If you cannot learn to act without
masters, you evidently will never become the real equals of
those who do.

What a number of distinct and different views of things you
must therefore hold steadily before you ! You must, on the one
hand, forget that any social prejudices stand in your way as phy-
sicians: but on the other hand you must remember that, in virtue
of these, you continue to have certain class interests, which can
not, with either justice or safety, be ignored. You must remem-
ber all that you have been taught; and yet you must soon cease
to think of what you have been taught in comparison with what
you must freshly learn. At certain times you must be able to sink
all immediate practical considerations in the interest of pure
ideas. Yet, to the pursuit of these, you must bring a tenacious,
practical energy, such as can scarcely be acquired except in con-
flict with practical emergencies. There is not a detail of your
career, theoretical or practical, individual or social, that will not
require the highest possible development of your powers of will.
This is, indeed, the sovereign power of human nature, without
which bright perceptions, good intentions, quick intuitions, flash
only for a moment to vanish in darkness. The beautiful para-
phrase of the English poet does not inaptly render the Bible
parable :

"Oh, well for him whose will is strong!
He suffers, but he will not suffer long;

402 Mary Putnam Jacobi

He suffers, but he cannot suffer wrong.

For him nor moves the loud world's random mock,

Nor all calamity's hugest waves confound,
Who seems a promontory of rock.

That, compassed round with turbulent sound,
In middle ocean meets the surging shock.

Tempest-buffeted, citadel-crowned."

OPENING LECTURE ON DISEASES OF CHILDREN,
AT THE POST-GRADUATE MEDICAL SCHOOL,
NEW YORK.^

Definitton. — At the outset of this course, which I am to
have the honor of dehvering to you, I deem it appropriate to
define the circumstances which serve to speciaHze diseases of
children in the wide field of human pathology.

Setting aside certain superficial practical considerations, we
may come at once to the consideration which constitutes the
basis of this specialization. It is the fact that the child represents
an organism in a state of continuously progressive development.
The details of this development may be classified into four groups,
namely : —

(A.) Those concerning the adaptation of the organism to a
succession of different media, and to a succession of changes in its
relations to surrounding objects.

(B.) Those concerned in an increase of bulk.
(C.) In an elaboration of structure.
(D.) In an evolution of function.
Transition to Different Media. — The successive adaptations
are necessitated by a series of transitions : —

(i.) From the placental to pulmonary respiration.
(2.) From vascular or imbibition nutrition to nutrition
through processes of ingestion and digestion.
(3.) From the recumbent to the erect position.
(4.) From passive nervous and reflex muscular action to
voluntary movement, mental action, and locomotion.

Rapidity of Change. — The rapidity and intensity of the
changes through which the infantile organism passes both in-
crease in proportion as we approach the birth point, and diminish
' Reprinted from the Boston Medical and Surgical Journal, 1883.

403

404 Mary Putnam Jacobi

as we recede from it. Thus the first hour, first day, first month,
first year, may each be considered as distinct periods, covering
changes of such magnitude as are effected in no other hour, day,
month or year of existence. For in the first hour of the birth
of the child, pulmonary respiration is established, involving a
complete alteration of the intra-cardiac circulation together with
extensive changes in that of the liver and entire abdomen. The
arterial blood pressure becomes superior to the venous: the
oxygenation of the blood passes from a minimum to a maximim:i ;
the functions of the heat-regulating apparatus, hitherto ren-
dered unnecessary by a medium of constant temperature, are
now initiated. During the first day the functions of the alimen-
tary canal are established ; the prehensile capacity of the mouth ;
primary digestion in the stomach and intestines ; absorption and
excretion. Extensive desquamation begins over the entire
tegumentary surface, — in the alimentary canal of epithelium, on
the skin of epidermis. This desquamation continues during
several days of the first month, and accompanies the first effort
of secreting activity on the part of the buccal, peptic, and intesti-
nal glands on the inner, and of the sweat glands on the outer,
tegument. The salivary and pancreatic glands do not elaborate
effective secretions until after the close of the first month. During
its first half, however, occurs the fall of the cord and healing of
the umbilical wound; the adjustment of equilibrium in the
hepatic circulation ; the empt)dng the middle ear of accumulated
epithelium, by successive efforts of deglutition; the habitual
working of the heat-regulating apparatus; the development of
the psycho-motor centres in the brain. The latter, according to
the experiments of Soltman, become for the first time responsive
to faradic excitation on the tenth day after birth in puppies.
It is probable with the much slower rate of development of the
human young that in them these centres become excitable much
later.

During the first year not only these but all the ganglionic
centres in the cerebro-spinal axis become elaborated in structure.
The special senses are trained, and the centres in which their
nerves terminate become habituated to decompose the impres-
sions these transmit to them. The power of voluntary movement
is acquired; the growth of muscles, of the bony skeleton, and of
the teeth in their alveolar cavities constitute prominent

Diseases of Children 405

phenomena of the physiological life. The heart doubles in size
(from a capacity of 20 cc. at birth to 40 cc); the lungs treble
themselves. (Beneke.)

The period of the child's life embraced between one and three
years is marked by the completed eruption of the teeth ; by change
in diet, and hence in process of digestion; and by the further
evolution of nerve centres connected with the acquisition of
speech, the awakening of intelligence, and the attained ability
for station and locomotion. The latter again implies continued
progress in the development of the musculo-osseous system.

Between the age of three and seven years begin the social
relations of the child; from seven to fourteen, and especially in
the latter years of this period, the growth of the body, and par-
ticularly of some of its organs, becomes again extremely active,
and preparation begins for the development and functions of the
reproductive organs.

Correlative with each period thus demarkated, we find a pre-
ponderating liability to some special morbid condition. The
correlation is rarely exclusive ; few diseases are absolutely limited
to any one period of life ; but there are preponderances indicating
an approximate limitation. An absolute limitation exists in re-
gard to the morbid conditions associated with congenital mal-
formations ; and also in regard to the group of diseases known as
those of the new born. The former are necessarily present at
birth, and discoverable in the first hour of existence. The latter
arise from possible accidents of parturition, or during the succes-
sive movements of transition effected during the first hour, day,
or month. Thus, in the first hour we may encounter the formid-
able accidents of asphyxia, and arachnoid haemorrhage, and the
far lesser danger of subperiosteal cranial haemorrhage constituting
cephalatoma, — all dependent on abnormal pressure received by
the child during the process of parturition. It is at the same
moment that the fatal apnoea of diaphragmatic hernia is also,
if ever, observed.

During the first day, or even the first two or three days,
secondary morbid processes consecutive to an asphyxia or
apoplexy of parturition are liable to appear. The infant whose
respiration has been established after laborious efforts may de-
velop pneumonia in consequence of intrauterine aspiration of
foreign matters into the air passages. This is a "Schluck-

4o6 Mary Putnam Jacobi

Pneumonic," analogous to that caused by section of the vagi
nerves, and paralysis of the glottis. A portion of the lungs may
remain unexpanded in foetal atelectasis, or subsequent portions
may collapse from weakness of the inspiratory efforts. Such
atelectasis is a not unfrequent accompaniment of meningeal
haemorrhage. The latter again, initiated during the birth process,
may continue to extend, not proving fatal till several days after
birth. The cerebral haemorrhage may of itself occasion no
characteristic symptoms, but by extension along the medulla, or
into the spinal membranes, may determine tetaniform convul-
sions.

Paralyses rarely or never arise from arachnoid haemorrhage,
but often coincide with them as a result of the same cause. The
cadaver that I here show to you is that of a child who was found
on the first day to be paralyzed in the right arm, and on the
second day began to exhibit symptoms of arachnoid haemorrhage
over the left cerebral hemisphere. But the paralysis was due to
compression of the right brachial plexus.

Meningeal haemorrhage is not always the result of a parturient
traumatism. It may be the expression of a puerperal infection,
its symptoms so dominate the rest, that they are overlooked.
Thus, the infective process tends, in the new bom as elsewhere,
to cause fever; but this tendency may be so checked by the
haemorrhage that the temperature falls even below normal.

Instead of paral3^is from compression of nerves, the child
may suffer fracture in one or more limbs. The baby I now show
you was born with fracture of the right humerus, and also of the
right femur. The mother was attended by a German midwife
who summoned a physician, and both together applied some
kind of splint to each injured limb. But the adjustment was so
imperfect, that to-day, two weeks later, the fragments of the
htunerus are still freely movable on each other, and the fragments
of the femur have united at an obtuse angle.

A prominent accident of the first day or days of infantile life
is umbilical haemorrhage. Certain English authors speak of this
accident as one easily controlled. This is, however, only the case
when it is dependent on a local process; but when, as is much
more frequent, the haemorrhage is the expression of constitu-
tional disease, it is usually fatal. Under this microscope are
slides representing sections from various tissues in such a case,

Diseases of Children 407

where the haemorrhage began two hours after birth, repeated
itself frequently, and proved fatal in ten hours. It depended on
a generalized fatty degeneration of the blood-vessels

This fatty degeneration may begin in foetal life, and be asso-
ciated with acute fatty atrophy of the liver (Hecker and Buhl) ;
or it may occur as an element of the complex process of the puer-
peral infection of the new born. This disease again may begin
before birth, and even run its entire course in utero, the child
being bom dead with lesions of general peritonitis. After birth
the same pyasmic process may be, now the cause, now the result
of inflammations of the navel, or of the umbilical vessels.

Pyaemia and the acute fatty atrophy or Buhl's disease are both
accompanied by severe icterus; a milder form of jaundice is
extremely common during the first week of life, the well-known
icterus neonatorum. The semi-physiological character of this
symptom invests it with more interest than it could derive from
its clinical importance. By some authorities it is considered only
apparent, and to be dependent on the flushing of the skin during
the process of the establishment of respiration and the des-
quamation of the cuticle. By others again it is associated with
the changes in the hepatic circulation. The tension is said to be
so lowered in the hepatic veins, after closure of the umbilical
vein, that bile passes freely into them from the biliary capillaries.
Finally, the icterus has been attributed to destruction of the
blood corpuscles, and this hypothesis again divides itself between
two theories: according to the first, the destruction takes place
within the blood-vessels at large, and the color of the skin de-
pends on the accumulation of haematoidin, chemically identical
with bilirubin. A much more tenable theory is based on the fact,
recently demonstrated, that icterus is associated with an excess
of the denutrition, — of the loss of weight, — normal to the first
days of life, before the digestive processes are able to compensate
the processes of waste. The blood corpuscles are attacked, in
common with other albuminoid substances are destroyed in the
liver, and their coloring matter occasions the formation of an
excess of bile.

On escaping from the sphere of parturient accidents or dis-
eases, and the time at which the various malformations may be
properly studied, the child passes during the second half of the
first month into a second region of liability, where disease de-

4o8 Mary Putnam Jacobi

pends on the imperfect function of organs. After the establish-
ment of pulmonary respiration, the initiation of extra-uterine
nutrition involves a series of processes, whose equilibrium is very
easily overthrown. During the period of normal insufficiency of
the digestion the metamorphosis of albuminoid substances — of
which part is derived from the stored albumen of the tissues —
is also incomplete. Hence, together with the formation of a
large amount of urea, — also occurs the formation of an excess
of uric acid. This may accumulate in the canaliculi of the kid-
ney, constituting the renal infarctus of the new bom; a lesion
constantly discovered after death from malnutrition during the
first weeks of life. '

A still greater degree of nutritive failure involves encroach-
ment upon the fixed albumen of the tissues, and the child visibly
emaciates. The imperfect digestion is indicated by acid fermen-
tations of food, with consequent colic, vomiting, diarrhoea;
or, as a result of the continued irritation of the digestive mucosa,
catarrhal inflammation sets in. The growth of thrush (oidium
albicans) is facilitated by the desquamation of epithelium
normal to the period. The ultimate result of these gastro-intes-
tinal disorders, if unchecked, is a state of profound and pitiful
denutrition, variously known as marasmus, atrophy, or athrepsia.

The tendency to gastro-intestinal disease persists throughout
the first year. A similar liability exists towards disease of the
respiratory apparatus, and for the same reason in both, namely,
the novelty of function. This contrasts with the immunity from
disease of such organs as the heart, liver, and kidneys, whose
functions have been exercised during several months of foetal
life. These organs seem to become liable to disease as they wear
out from long use, not as they enter upon their functions.

During the first year two constitutional diseases first show
themselves, hereditary syphilis in the first quarter, rachitis in
the second quarter or half. Both depend on perversions of nutri-
tion, on the one hand, through the influence of a specific virus;
on the other, through digestive failure and anasmia.

The three remaining periods of morbid liability can only
be defined approximately. Thus, from the age of one to three,
there is a greater tendency to certain forms of nervous disease.

' Virchow supposed that the renal infarctus is normal to the new bom.
But this hypothesis has been rendered improbable.

Diseases of Children 409

The maximum liability to meningitis is at two years. (Rilliet
and Barthez.) Convulsions are associated both with processes of
dentition (through the medium of a co-existing rachitis) and with
digestive disorders, the latter frequent from the change of diet
at weaning. The evolution of function in the nerve centres
at this period of life constitutes a predisposition to nervous
disorder. Scrofulous malnutrition, tuberculosis may be assigned
to this same period, because, on the whole, it is then that they
most frequently manifest themselves for the first time.

The fifth period, embracing the four years from three to
seven, is especially characterized by the liability to infectious
diseases, as diphtheria, the eruptive fevers, pertussis. This
tendency is evidently associated with and partly caused by the
widening social relations of the child, by which he is much more
easily and frequently brought into contact with sources of in-
fection.

Finally, the sixth period, extending from seven to fourteen,
continues the morbid tendencies of the last two ; shows a greater
tendenc}^ to diseases of the osseous system; exhibits more dis-
tinctly the marks of constitutional anaemia, and develops the
liabilities to rheumatism, and to certain neuroses, for example,
chorea, epilepsy, hysteria.

As we approach the birth point in the survey of the child's
history, we are made aware of the persistent influence of many
conditions which have dominated foetal and embryonic life.
The process of cleavage, the process of curvature, the principle
of inequality in the growth of parts, and that of mutual limita-
tions of growth, govern, taken together, the course of embry-
onic evolution. They constitute a set of mechanical conditions
which, in continuation with the one vital process of continuous
growth, suffice to produce the marvelous results of that evolution.
The mechanical influence, principally of pressure, is exerted in the
first place by the membrane investing the embryonic mass,
or, in other words, by the external medium; in the second place
by the parts of the organism reciprocally upon one another.
Throughout childhood this special susceptibility to mechanical
influences persists, and, as in embryonic life, these are exerted
first, by the external medium upon the growing organism,
second, by the parts of that organism reciprocally upon each
other. This is a fundamental fact which offers the key to many

410 Mary Putnam Jacobi

of the peculiarities of infantile pathology, as we propose to show
in detail.

The fertile results which may be obtained from the simple
influence of continuous pressure exerted upon masses continually
increasing in size is remarkably shown in the process of cleavage.
This is not primary or self-determined, but is brought about,
first, by the pressure of the investing membrane upon the proto-
plasmic masses, second, by the retractile force of these masses
themselves. The segmentation of the ovum — the first step in its
development after fecundation — offers the first example of this
process. This diagram, enlarged from Kolliker, exhibits the
segmentation of the ovum of an ascaris. The second example is
found in the cleavage of the blastoderm into three layers: the
ectoderm, entoderm, and mesoderm. It is shown in this diagram.
The formation of the cleft for the spinal column, of those for the
pleuro-peritoneal cavity and pharynx, of the bronchial clefts,
the segmentation of the provertebrae, and finally the segmentation
of the limbs, are all important illustrations of the process of
cleavage determined in each case by the double mechanism above
described.

After birth no cleavage process ever occurs, but we encounter
several pathological conditions dependent on errors of cleavage,
on its excess, more rarely on its deficiency, most often on the
persistence of clefts, which, in the normal course of development,
should have become closed. A complete cleavage of the ovum,
previous to the differentiation of its parts, results in a twin
pregnancy. It implies an excess of formative material, but may
be considered as the first step towards a monstrosity. (Ahlfeld.)
Partial cleavage of the caudal or cephalic extremity, or both, re-
sults in the development of different kinds of double monsters.
Excess of cleavage at the extremity of the limb buds causes
supernumerary fingers or toes. I here show you a child present-
ing such a deformity. The process of cleavage, continuing after
the different fingers had been differentiated, has split up the
thumb segment into two unequal parts. In the larger or internal
segment the two phalanges continue in a straight line with the
metacarpal bone. The smaller external segment stands out at
an angle with the metacarpal bone, being apparently articulated
with a facet on its distal and outer extremity.

Failure of cleavage determines various degrees of apparent

Diseases of Children 411

fusion of parts, a deformity again principally observed in the
limbs. Web fingers or toes constitute the lightest grade of this
deformity. The fingers are well formed, but ■ -nnected by a
fleshy membrane, not difficult to divide, but w .ose parts show
an almost incoercible tendency to grow together again. The
fingers may, however, bV lused into a solid mass; the two lower
extremities may remain united in a species of tapering tail, and
constituting the viable monster known as the siren.

The most numerous malformations, however, connected with
the process of cleavage are those which result from a failure to
close of a cleft destined only for temporary existence. Thus per-
sistence of an extensive portion of the dorsal cleft determines a
hemicephalus, of a more limited portion, with protrusion of
the spinal membranes, a spina bifida. Of the latter malformation
I here exhibit to you a living specimen. The hernial tumor is
situated, as you will notice, in the seat of election, the lumbar
region, the vertebral arches being here entirely deficient. The
greater frequency of spina bifida in this region is explained by
the fact that closure of the dorsal cleft is effected from above
downwards, as is shown in this diagram. Hence the lumbar
region remains open for the longest time.

I defer more detailed study of this interesting case to another
occasion. I merely point out here that the hemispheric tumor,
as large as half of a large orange, is deprived of skin, and its thin,
membranous surface superficially ulcerated; that the child,
which is seven months old, though enjoying fair health, is much
emaciated, and, for a month or two, has exhibited the symptoms
of a chronic internal hydrocephalus; finally, that the lower
extremities are congenitally paralyzed, and both feet are in
marked talipes calcaneus. It is probable, therefore, that a
dropsy of the central canal of the cord exists, which has gradually
extended to the ventricles of the brain, of which the central canal
is normally the continuation.

On the anterior surface of the body malformations are fre-
quently encountered, which result from failure of union of the
lateral segments of the body. Hare lip and cleft palate (the
deformity is shown in this baby) are caused by the failure of
fusion between the superior maxillary processes, with the frontal
or intermaxillary process. The relative position of these parts
at the eighth week of foetal life is shown in this wax model. The

412 Mary Putnam Jacobi

deformity caused by the interruption, between the ninth and
tenth week, of the normal process of fusion, constitutes ninety-
nine per cent, of all cases of malformation of the face.

Fissue of the sternum, or, from partial failure to close of the
abdominal plates, umbilical hernia, and vesical ectopia, may
be mentioned as further illustrations of malformations dependent
on abnormal persistence of cleavage. On the lateral walls of the
foetus partial persistence of the bronchial clefts leads to certain
congenital cysts of the neck; while within the pleuro-peritoneal
cavity, though the abdominal plates be closed, failure in the
development of one lateral half of the diaphragm necessitates the
fatal accident of diaphragmatic hernia.

"It is no explanation," observes Ahlfeld, of these malforma-
tions, "to say that they result from an arrest of development.
The question is, What has caused such arrest?" and the author
assigns five principal causes: first, an insufficiency of formative
material; second, pressure from without of too tense amniotic
membranes, together with, possibly, deficiency of amniotic
liquor; third, pressure from within of dropsical effusions; fourth,
interposition, or even adhesion of amniotic folds; fifth, prolapse
of some part between the segments destined for fusion.

The process of curvature is as important as that of cleavage
in embryonic evolution. To understand its causation and conse-
quences, His advises the student to take a cylinder of wax and
slowly press down one extremity towards the other, in the
long axis of the cylinder. This will cause a bulging out on each
side of the compressed extremity, and the development of a
transverse cleft running across it, and connecting the bulging
points. The cleft becomes more apparent when a hollow cylinder
of India rubber is used, instead of a solid cylinder of wax, and the
extremity is curved forward at the same time that it is com-
pressed. It then not inaptly represents the buccal cleft, which
develops across the cephalic extremity of the embryo, at the
moment that this undergoes the so-called "cephalic curvature"
forwards. This curve is shown on this wax model, and also on
this diagram enlarged from His. Not only the buccal cleft and
cavity, but the lense cavities are formed by this same mechanism;
the oculo-nasal cleft is deepened, the forehead acquires promi-
nence, and lateral folds or ridges are thrown up in the neck,
between which the bronchial clefts are destined to appear.

Diseases of Children 413

The cephalic curvature is observed only in the embryos of
mammalia, birds, reptiles; and these alone exhibit the develop-
ment of the amniotic fold over the cephalic extremity, known
as the amniotic hood. His derives the first of these nearly con-
temporaneous processes from the second, showing that the pres-
sure of the amniotic fold upon the constantly growing head
of the embryo necessitates the forward curvature of the latter.
The mechanical influence of pressure, combined with the single
vital process of continuous growth, thus again suffices to de-
termine most complex results.

The same influence of external pressure is continued after
birth, throughout infancy and childhood, and, indeed, until all
portions of the organism have become solid enough to resist it.
The physiological curves of the spinal column are developed by
the weight of the head and shoulders when the child begins to
assume a sitting and upright position. When the weight to be
supported increases out of proportion to the process of consolida-
tion in the vertebrae, and it become unequally distributed, the
pathological curves of scoliosis are formed. The fact, recently
established by Beneke, of the great increase in the volume of the
heart and lungs about the period of puberty is probably correla-
tive with the special morbid liability to scoliosis noted for this
same period. The greater size of the right lung, which has often
been alleged as at least one cause of the curvature of the cervico-
dorsal spine to the right, may more plausibly be considered so,
when it is known that the lungs at early maturity have attained
to twenty times their volume at birth. The heart, whose incli-
nation towards the left should balance the excess of weight of
the right lung, only increases twelve or thirteen times its original
size. But it has been further noted by Beneke, that, in anaemic
and phthisical persons, the development of the heart which should
take a sudden leap forward during the year of the establishment
of puberty remains insufficient, and does not attain the size
which is needed as a make- weight to the lung. ^ It is precisely
such persons as are most liable to the scoliosis of adolescence.
They are also liable to excess of growth of the osseous frame-
work of the body, out of proportion to the vigor of its viscera;

' The influence of such defect in lowering the force of the pulmonary
circulation, facilitating caseation of inflammatory products, is of course of even
greater importance.

414 Mary Putnam Jacobi

hence, again, to an excess of weight to be supported by an
abnormally soft spinal column.

The more extensive softening, especially of the intervertebral
disks, caused by rachitis, occurs at an earlier period, while weight
is evenly distributed, and the influence of sitting postures, right
arm exercise, etc., have not yet been experienced. The curve,
then, instead of being lateral and partial, is general, as in cyphosis.
A case of this kind in an extremely rachitical boy of five years
old was sent to my clinic as paralyzed. He indeed could not
walk nor hold his trunk erect; but upon being supported in a
plaster jacket he was able to do both, and under the use of
cod-liver oil, iron, and lime, entirely recovered.

Depression of the ribs, of the cranial bones (cranio-tabes),
curvature of the femurs and tibiae, are all well known results of the
influence of pressure steadily exerted upon the softened bones of
rachitical children. The lower limbs frequently exhibit the
characteristic curvatures before they have ever borne the weight
of the body. The deformity seems, then, to be attributable to
the inability of the extensor muscles to correct the attitudes of
flexion first assumed by the limbs.

Another interesting illustration of the influence of weight,
or the pressure exercised by it, is offered by the deformities con-
sequent upon infantile spinal paralysis. A certain number of
authors have explained these deformities by the persistent terms
of non-paralyzed muscles whose antagonists had been paralyzed.
In reality, however, the deformity is due to the influence of a
weight which tends to press the limb in a certain direction, from
which the paralyzed muscles are unable to withdraw it. Rachitic
paresis of muscles or softness of ligaments have the same result.
The weight of the body pressing in the direction of the long axis
of the femur from above downward, and from without inward,
comes against the internal lateral ligament of the knee-joint,
and being insufficiently resisted by the contraction of muscles
which should maintain the leg in a straight line with the thigh,
constantly exaggerates the angle existing between these two
segments until genu valgum results. Valgus of the foot is formed
when similar pressure is exerted at the internal lateral ligament
of the ankle-joint; flat foot when the arch of the foot is pressed
down by a dead weight inadequately taken up by the elastic
force of plantar muscles and ligaments.

Diseases of Children 415

The effects of pressure are most striking in relation to an
undeveloped organism, because the part which has been deviated
in a vicious direction continues to grow in that. The effect of
the deviation, therefore, not only persists, but continually tends
to increase. But all living parts, even ceasing to increase, are
subjected to a constant molecular change by the movements of
nutrition, and these movements are liable to be deviated in an
increasingly intense degree by the influence of even an unvarying
pressure even in an adult or slowly growing part. Hence thera-
peutic influences are of much value. Pressure and position may
be utilized to promote lymphatic absorption ; to change currents
of circulation; to determine local atrophy. Probably the value
of such mechanical agencies is as yet only imperfectly appreciated.
Their power is best to be learned by studying their influence
upon embryonic evolution and in the physiology and pathology
of childhood.

The third fact of embryonic development which we find still
potent in childhood is the inequality in the rate of growth of
different parts of the organism. This unequal growth is, during
embryonic life, an important factor in the formation of the
folds, clefts, and curves we have just been considering. After
birth, the same inequality persisting, determines a succession
of phases, both in physiological function and capacity, and in
morbid imminence. It is incorrect to assert that at birth the
child is an entirely imperfect being. The functions of capillary
circulation, of molecular nutrition, of urinary excretion, are per-
formed with more surety and vigor than at many other periods of
life. The dangers arising from novelty of function in the respira-
tory apparatus and the great susceptibility to cold are largely
compensated by the peculiarities in the relations between the
heart and the lungs. During infancy the pulmonary artery re-
mains wider than the aorta, and pressure in the pulmonary ex-
ceeds that in the systemic circulation. Extensive obstruction to
the circulation, with obstacle to the work of the right heart,
occurs, therefore, less frequently than in adult life, where the
conditions are reversed, and the force of the pulmonic circulation
falls below that of the systemic. Hence paralysis of the heart
from mechanical causes, as the obstruction to the circulation
caused by pneumonia, is less liable to occur - and thus pneimionia
is really a less dangerous disease in children than in adults.

4i6 Mary Putnam Jacobi

During foetal life marked inequality exists in the distribution of
oxygenated blood. This comes from the placenta by the um-
bilical vein, and, brought to the heart by the inferior vena cava,
is carried directly across the right auricle to the foramen ovale
by means of the Eustachian valve, that really forms a special
channel for its conduction. It is this blood which reaches, almost
unmixed, the left ventricle, to be thence thrown through the
aorta and the vessels springing from its arch towards the cephalic
extremity of the foetus, towards the brain, and more especially
the medulla, with its important cardiac and respiratory centres.
These, therefore, get a special start in development. On the
other hand, the venous blood returned from the head and the
upper extremities enters the right auricle in front of the
Eustachian valve, or channel, and, by the pulmonary artery and
ductus arteriosus, reaches the descending aorta, to be distributed
unmixed to the lower half of the body. This, therefore, remains
retarded in development as compared with the upper half, and
not only the limbs, but the lower portion of the spinal cord, with
the ganglionic centres governing the limbs and the pelvic organs.

Now it is a fact that the lumbar portion of the cord and spinal
column show% certainly throughout childhood, a morbid im-
minence superior to that of the upper portions. Osteo-myelitis,
in the one, anterior poliomyelitis in the other are much more
frequent in the lumbar than in the dorsal or cervical regions. We
have already alluded to the predilection of spina bifida for this
region, where the vertebral arches are the last to close. May we
not consider all these facts as the consequences of a nutrition,
defective in comparison with that of the upper nerve centres and
spinal column? We may even go further and trace to such dis-
proportion, failing to lessen, or even increasing, with advancing
years, such imperfect development of the utero-ovarian system
in many anaemic children as entails disease as soon as these
organs enter upon function. If the maximum nutritive currents
of the body only just touch par the minimum cannot fail to fall
below the level of healthy vitality.

The foregoing considerations are theoretical. Practical pre-
cautions of great importance are required in the adjustment of
external media to the unequally unfolding organism of the child.
The adjustment of foods to the successive phases of development
of the digestive organs; of effort to those of the locomotor appara-

Diseases of Children 417

tus; perhaps, most difficult of all, of action and rest to the com-
plex phases in the development of different parts of the nervous
system. It would carry us much too far to show how profoundly
this principle enters into the guidance of mental development;
and how much it has been overlooked until most recent times.
The child's mind and body for centuries has been looked at
simply as a miniature of the man's; the fact that the inter-relation
of their parts was differently proportioned has, until now, been
most dimly apprehended.

The final principle to which I would call your attention is
that of the mutual limitation of parts. In the embryo the natural
termination of the growth of any mass of cells is effected when it
is brought in contact with an opposing mass, growing with equal
or superior vigor. Failure in the establishment of such limiting
contact results in the undue growth of the first mass of cells.
An interesting illustration of such failure drawn from infantile
pathology is suggested by a remark of Bouchard. This author
would explain the excessive growth of the medulla, of bones in
rachitis, by the defective calcification of the bones. The med-
ullary elements, insufficiently imprisoned in calcareous envelope,
are left free to develop immoderately.

Diminution in the calcareous matter of long bones, occasioned
by prolonged febrile diseases, may similarly help to explain the
growth of the patient, which is often observed in convalescence
from such diseases. The medullary elements undergo a nutritive
irritation in virtue of the febrile disease; this coinciding with a
diminished resistance in the osseous envelope is liable to deter-
mine in adolescents a sudden increase of growth, which is not of
good augury, inasmuch as nutritive material is thus withdrawn
from nervo-muscular tissues greatly in need of repair. This same
reason justifies the popular dread of "outgrowing the strength,"
a process frequently observed in delicate children or youth.
When, moreover, with elongation of the skeleton the heart and
lungs fail to grow in proportion; when, by increasing length
of the neck, the brain is removed farther from the heart, and thus
receives its impact of blood less forcibly, muscular weariness,
anaemic headaches soon result.

These few examples may serve to illustrate a principle whose
application is probably far-reaching. It is possible that the
primary reason for the development of neoplasms consists in a

41 8 Mary Putnam Jacobi

failure of normal tissues to limit the growth of certain elements
either homogeneous or heterogenously imprisoned in the organ-
ism at birth. (Cohnheim.)

The foregoing most cursory survey briefly indicates the line
of thought which seems to me most profitable to pursue in study-
ing the diseases of children. With all considerations drawn from
general pathology are to be combined those based upon the
special fact of continuous growth of unequally rapid evolution.
The morbid conditions altogether peculiar to childhood are to
be understood only by reference to circumstances of develop-
ment. Study of disease common to children and to adults must
be outlined in its main features in the latter, but then specially
adapted to the former, and peculiarities explained by, again,
peculiarities in the phase of development. And to thoroughly
understand the meaning of developmental processes these must
be studied where they are most rapid and their results most vivid
and striking, namely, in the embryo and foetus. Here may be
first acquired the full conception of the wonderful flexibility of
living things, of the ceaseless rush of life towards its goal; of
the curve of changes so incredibly rapid at the outset, so gradu-
ally slackening throughout childhood towards the relative
stability of adult existence, to finally recommence, substituting
for the original increment a constant decrement of force, until
the wave of life terminates in death.

THE INDICATION FOR QUININE IN PNEUMONIA.^

Mr. Mill closes a review of the poems of Alfred de Musset
with the remark, "How much life is required to produce a little
poetry!" Similarly, I think, no one can sift clinical records
without feeling inclined to exclaim, "What an enormous amount
of data are required to justify a few positive conclusions!" On
this account, fresh observations are always in order, and this is
my excuse for presenting the partial conclusions which may be
deduced from a hundred dispensary cases of pneumonia treated
by quinine.

It would seem, at first, as if lOO cases would suffice for many
and quite positive conclusions. But the uncertainty of dispen-
sary practice is so great that, out of this lOO, only 33 cases were
followed to complete termination. In 20 others the record con-
tinues until after marked defervescence had occurred, making a
fairly satisfactory total of 53. In 20 other cases the record stops
during the continuation of fever or of marked physical signs,
while in 28 cases the patients were only brought to the dispensary
on a single occasion. The age of the patients varied from three
weeks to eight years, much the larger number being about two
years and a half old.

From the incompleteness of so many of the histories, it is
useless to attempt positive conclusions in regard to the mortality
statistics. Out of the whole number, seven are known to have
died, so that the mortality can not be less than seven per cent.,
while it may be greater. But, on the other hand, the conditions
were so generally unfavorable that it is impossible from these
data to estimate the chances of death from the disease under
quinine treatment, when all the details of management should
be under the physician's control. Of course, all the cases brought

' Reprinted from The New York Medical Journal, 1887.

419

420 Mary Putnam Jacobi

to the dispensary were, by that fact, submitted to a degree of
exposure which would be carefully avoided in either hospital or
private practice. The general hygiene of the house was usually
bad, the nursing unskillful and often inattentive, and a ten-
dency to caseation and tuberculization existed very frequently,
either constitutional or as a result of measles. One of the seven
deaths occurred in a pneumonia following diphtheria ; in another
case it was consecutive to scarlet fever. Setting aside the mor-
tality statistics as entirely inadequate for any useful purpose,
the data may be utilized in the inquirv how far the fever or the
physical signs of pneumonia are demonstrably influenced by
quinine.

The physical signs especially investigated were the com-
bination of extremely harsh or of bronchial breathing with
dullness on percussion. In a few cases tympanitic percussion
sound existed over areas where the auscultatory sounds would
have led the observer to expect dullness. This paradoxical
phenomenon is best explained by the German theory, which
ascribes it to some such infiltration of the walls of the air-cells
as may prevent them from vibrating under percussion. The
column of air then vibrates alone — gives rise to homogeneous
vibrations, as shown by experiments with the sensitive gas-
flame — and such homogeneous vibrations have a tympanitic
resonance. Similarly, percussion over the stomach normally
occasions a tympanitic sound, because the walls are too flaccid
to vibrate. But if the stomach be first overdistended, or, con-
versely, if healthy lungs be removed from the body, and per-
cussed in their relatively collapsed condition, the note becomes
duller in the first case, tympanitic in the second. Upon inflating
the lungs, however, and repeating the percussion, the tympanitic
note is found to have disappeared.

This experiment is mentioned by both Weil and Gerhardt
in their treatises on percussion and auscultation. I have repeated
the experiment, and obtained exactly the results stated. I have
made somewhat of a digression to mention these facts, because
I have found them omitted by many English and American
authors.

Clinically, tympanitic percussion sound with consolidation
often coincides with caseous degeneration of the lung, and the
theory would therefore be sustained by the peculiar infiltration

Indication for Quinine in Pneumonia 421

of the alveolar walls known to characterize Buhl's desquamative
pneumonia.

To return to the clinical analysis. Seventeen of the cases
examined had blowing respiration in some portion of the lung,
usually in the upper scapular region, and among these i6 had
fever. Forty-eight cases exhibited tubular breathing, and among
these only 2 were without fever at the time treatment was begun.

To nearly all these cases quinine was administered in about
the same way. Five grains were given at night, and the same
amount in the morning, each in two doses at an hour's interval.
In babies under eight months old, two grains and a half were
given night and morning, similarly divided. In one or two cases
requiring special mention, to children over two years old, larger
doses were given. Out of the 16 cases of the first class, with
harsh and blowing respiration, usually, of course, accompanied
by rS.les, and other signs, physical and rational, that I need not
here particularly describe, the blowing respiration disappeared —

After 2 days in 3 cases;

" 3

" 2

<<

" 4

" 6

i<

" 5

" I

case

" 6

" I

<<

" 7

" I

(1

" 14

" I

<<

In the apyretic case with blowing respiration this had dis-
appeared after two days' medication.

In the second class, where tubular breathing indicated more
intense congestion, or even consolidation of the lung, this was
relieved, as shown by the disappearance of the sign —

After 2 days in 3 cases;

" 3 " " 3 "

" 3 " " 3 "

" 6 " •' I case;

" 7 " " 5 cases;

" II days in i case;

" 14 " " I '•

" 17 " " I "

" 18 " " 3 cases;

" 3 weeks" i case.

Two cases, without fever, lost their tubular breathing in
one and ten weeks respectively.

422

Mary Putnam Jacobi

Twenty-four cases were not observed to complete termi-
nation, the patients ceasing attendance. In lo of these the
fever had almost disappeared, and the patients were greatly
improved when lost sight of; there was every reason to be-
lieve that they completely recovered. But in these, when
last seen, the tubular breathing was persisting —

After 2 days in 3 cases;

" 6 " '

I case;

" 7 " '

2 cases;

" 9 " '

I case;

" 12 " '

I "

" 18 " '

I "

" 6 weeks '

I "

Among the patients lost sight of while the fever was still
high, and the morbid process progressing, the tubular breathing
was persisting —

After 2 days in 6 cases;

" 3 "

" I

case;

u ^ ..

" 5 "

" 7 "

" I
" I
" 2

11
cases;

" 10 "

" I

case;

" II "
" 12 "

" I
" I

<i

The tables of cases in which the patient was under ob-
servation until the physical signs had been effectively modi-
fied show that this modification occurred at varying intervals
during the first week from beginning of treatment in 29 cases,
and in from eleven to eighteen days in only 7 cases; finally
after three weeks in i case. On this account, the persistence
of tubular breathing during from two to seven days in 17 cases,
which were not watched to their termination, proves nothing
against the final recovery of the patients. Such recovery was
almost certain, moreover, in 6 of these 17 cases, because, not-
withstanding the persistence of tubular breathing, marked defer-
vescence had occurred, and the patient was evidently entering
upon convalescence. The possible occurrence of fresh attacks,
or of extension of the morbid process to other parts of the lungs,
would prove nothing against the favorable modification of
the first set of symptoms by the treatment.

Indication for Quinine in Pneumonia 423

In 10 cases tubular breathing developed while the patient
was receiving quinine. The treatment had been instituted
when the occurrence of hurried and harsh respiration, together
with fever, had pointed to a commencing broncho-pneumonia
in scattered or in deep-lying foci. The appearance of the tubular
breathing after two or three days of quinine medication indicates
that in these cases the extension of the morbid process, or the
agglomeration of the pneumonic foci, was not averted by the
treatment. In 4 of the cases the lungs cleared up on the fourth,
seventh, tenth, and fourteenth day, respectively. In 6 the pa-
tients were lost sight of on the second, fourth, fifth, and seventh
day, and the tubular breathing persisted. To svun up such re-
sults as were obtainable from the data, we may say that quinine
was given in 59 cases which could be watched to the beginning
of convalescence or to death. Seven cases proved fatal, either
during the height of the acute attack or by the supervention
of acute tuberculization.

In 29 cases blowing or tubular breathing disappeared in
from two to seven days, in 7 cases in from eleven to eighteen
days, in i case after three weeks, thus making a total of 37 cases.

Finally, in 10 cases, though defervescence was established,
the tubercular breathing was persisting in from two days to
six weeks; thus in about one fourth as many cases as those in
which it disappeared. But these 10 cases represented convales-
cence, and may be added to the 37 cases in which the physical
signs disappeared with the fever. In addition to the pyretic
cases, quinine was given in 5 apyretic cases of chronic consolida-
tion of the lung, and in one of congestion from mitral insuffi-
ciency.

As these cases bear particularly upon the view of quinine
to be advocated in this paper, a summary of each will be given.

Case XXXVIII. — Two and a half years; broncho-pneumonia
fourteen days after measles; first seen May loth; harsh and
laborious respiration at right apex; t. 100.5°. ^ Vin. seneg. and
am. carb.

May I2th. — No improvement. I^ Potass, chlor,, sod. bicarb.,
syr. ipecac, inf. prun. virg.

13 th. — Abundant rales upper half right lung; respiration
very harsh; expiration blowing at apex. I^ Poultice. Qui-
nine, gr. V, night and morning, in two doses at an hour's interval.

424 Mary Putnam Jacobi

iQth. — Vomited after quinine; rales diminished; expiration
still blowing; t. ioo°. I^ Quin., gr. ij, every two hours.

22d. — Much improvement in general appearance; no fever,
no rales, no vomiting; expiration, however, tubular, at apex.
Continue quinine, but in five grains, night and morning, as on
15th.

The treatment was continued with progressive improve-
ment until on June 9th the tubular breathing was found to
have disappeared. The quinine was then suspended. I^ Syr.
tolu.

June i6th. — Return of cough; tubular breathing found at
left apex. Resumed quinine; continued until —

30th. — When tubular breathing entirely gone. Quinine
suspended.

Case LIV. — Child two years; first seen December 4th;
pneumonia lasting since measles in September; dullness and
increased vocal resonance at both apices; whiffs of tubular
breathing; t. 99.5°; glands of groin enlarged. I^ 01. morrhuae
and calcii phosphatis.

January 2gth. — Child reported as having entirely recovered.
Then acute attack, ushered in by convulsion; t. 102.5; R- 48;
harsh respiration over both lungs without rales. I^ Quin,, gr.
V, morning and night, in two doses each time.

31st. — T. 99°; R. 36. Continue quinine.

February 5th. — Respiration harsh and blowing at both apices.
Continue quinine, also ol. morrhuae and calcii phos.

igth. — Respiration nearly normal. I^ Quin., gr. ijss., night
and morning. Tinct. capsici externally.

March 12th. — Recovery complete.

Case VII. — Chronic pnetmionia or peribronchitis; boy aged
ten. On August 31st tubular breathing at right apex; no fever.
I^ Quinine, gr. v, night and morning.

September 23d. — Only occasional whiffs of tubular breathing
in right supra-spinous space. Continue quinine.

October 12th. — Respiration only tubular on forced breathing.

Case XXXVI. — Aged two and a half years; cough for four
months; slight tubular breathing at apex of right lung; t. 100°;
on October 25th, quin., gr. v, night and morning in divided doses.

2yth. — No tubular breathing; respiration harsh; t. 98.5°;
apparent improvement.

Indication for Quinine in Pneumonia 425

Case LVI. — Child aged three months; cough for five weeks;
bronchial breathing with dullness at right apex. On February
5th, quinine, gr. ij., night and morning.

February 12th. — Tubular breathing at right apex. Continue
quinine, also ol. morrhuae and calcis chlor.

igth. — Cough lessened. Continue.

23d. — Tubular breathing gone; replaced by harsh respira-
tions, with subcrepitant rales.

Case VI. — Boy aged nine months; rheumatic mitral insuffi-
ciency without hypertrophy; much dyspnoea and cough. Pre-
sumed hyperasmia of bronchial mucosa. Digitalis for three
days, without obvious effect. Then quinine, gr. v, night and
morning. Three days later child much improved; no cough;
cheeks and lips red instead of bluish.

In 32 cases the fever was observed to entirely disappear,
or to fall to 101°, under the quinine medication. This deferves-
cence occurred —

On the 2d day in 8 cases;

" 3d

' " 3

" 4th

' " 3

" 5th

' " 5

" 6th

' " 2

" 7th

' " 4

" 8th

' " 2

" loth

" nth

" I2th

" 13th

" 19th

case;

32 cases.

Thus in 25 cases defervescence occurred within seven days
after beginning the quinine; in seven cases it was later. In 14
of the 32 cases the physical signs persisted though the tempera-
ture fell, 12 of these cases having tubular breathing.

In the remaining 18 cases the physical signs disappeared,
or were greatly modified, coincidently with the fall of the tem-
perature.

In 19 cases more or less fever, sometimes as much as 105°,
was found on the last visit of the child, which occurred —

426 Mary Putnam Jacobi

After 2 days in 7 cases;

" 3 '

1 case;

" 4 '

2 cases;

" 5 '

2 "

" 7 '

I case;

" 9 '

I "

" 10 '

2 cases;

" 12 '

3 cases.

In 4 of these 20 cases the physical signs had greatly im-
proved, although the fever persisted. In the remaining 16
the physical signs also remained unchanged. Comparison
of this table of 19 apparently unfavorable cases with the table
of 32 cases in which defervescence was positively observed some-
what diminishes the unfavorable aspect of the incomplete cases.
For a delay of defervescence as far as the seventh day, observed
in 13 of the latter class, is not at all exceptional in cases of perfect
ultimate recovery, for it occurred in 25 out of the 32 undoubtedly
successful cases. The remaining 7 of these, moreover, delayed
defervescence as long as, or longer than, the remaining 6 of the
second division.

The temperatures existing at the time the quinine treat-
ment was begun varied from 103° to 105°. Within this range
the height of the temperature did not seem to modify its resis-
tance to medication. On the other hand, an increased amount
of quinine did not seem to exercise any greater influence over
the fever than the ten grains a day habitually given.

Thus, in one case early in the series a child of six months re-
ceived, in divided doses, ten grains of quinine in the evening
and five in the morning. This was weU tolerated, and, on re-
porting two days later, the child seemed much better, the
respiration was easy, and the temperature 100°. Tubular
breathing was heard bilaterally at the root of the lungs, and the
percussion resonance was diminished over both lungs. The qui-
nine was reduced to five grains night and morning. Two days
later the temperature rose to 105°, the tubular breathing had
disappeared, but the child was vomiting and the amount of urine
diminished. Quinine was given by rectal injection, and again
to the amount of fifteen grains in twenty-four hours. It was
nearly all rejected, but on the two following days ten grains were
administered in two doses by the mouth after two days ; the tem-
perature was still at 103°, the respiration 60, and the pulse 140.

Indication for Quinine in Pneumonia 427

The mother then ceased attendance and medication for a week,
rather wisely as it proved, for at the end of that time the baby-
was in full convalescence, the temperature ioi°, the respiratory
signs almost normal.

The foregoing case is, I think, of value, purely as a physiolo-
gical experiment, in showing the resistance of pneumonic fever to
doses of quinine which might be considered overwhelming for a
child of six months of age. Another case, not included in the fore-
going list, exhibits the same resistance of febrile temperature to
larger doses of quinine under somewhat different circumstances.

A boy of four years entered the infirmary with a history of
pneumonia following measles, and of four weeks' duration.
Over the upper fourth of the right lung and nearly the whole
of the left the respiration was extremely harsh in both times,
with the expiration prolonged but not tubular. Moderate flat-
ness on percussion existed over the upper fourth of both lungs,
but over the middle third of the left was a markedly tyra-
panitic resonance, prolonged into the axillary space. Notwith-
standing this situation, which seemed favorable to the theory
of tympanitic resonance from the stomach, I regarded the sign
as probably indicative of commencing caseous infiltration. The
child at first received five grains of quinine night and morning,
and this was continued several days as an experiment, and to
ascertain if the signs of pulmonary congestion would be modi-
fied by larger doses of quinine. Twenty grains of the drug
were administered in twenty-four hours, in divided doses every
six hours. During the second twenty-four hours of this medi-
cation, which was apparently well tolerated, the temperature
rose to 102.5°, and continued to rise every evening after the
larger doses of quinine were stopped.

The hectic thus developed was attributable to the tuber-
culization of the lung that became soon manifest; but it was
clear that the fever was not even symptomatically checked by the
quinine.

In a third case, a baby four months old, with signs of broncho-
pneumonia at the apex of both lungs and a temperature of 102.5°,
received a grain of quinine every two hours. Much of this was
vomited. Three days later the temperature was still at 102°,
and the physical signs unchanged. The use of quinine was
interrupted for two days, then resumed as before, together with

428 Mary Putnam Jacobi

camphor and brandy. The temperature was then 103°. Two
days later this temperature was unchanged, though the quinine
had been retained. The tubular breathing, with rales, had ex-
tended to the middle of the right lung. Three days later the
temperature was 106°. The left apex and the upper half of the
right lung solidified.

At this point the child was lost sight of. Whether, as was
only too probable, it died could not be ascertained; but it is
certain that the large doses of quinine entirely failed to prevent
either the rise of temperature or the extension of the morbid
process in the lungs. Between the extreme and special cases
just mentioned, and which in this series are the only ones re-
corded as those in which more than ten grains of quinine were
given daily, and the mass of the cases in which precisely this
amount was given, lies a considerable range of possibilities for
varying methods of medication. Into these, of course, the
reasoning of this paper can not enter. But, from the data given,
the positive conclusion can be drawn that, in the pneumonia of
children between six months and four years of age, a daily dose
of ten grains of quinine does not act as an antipyretic per se,
does not reduce temperature directly and apart from the morbid
process, but only in so far as it modifies this.

It is true that in fourteen out of thirty-two cases defer-
vescence occurred while signs of consolidation still persisted
in the lungs. But it is well established that such signs do not
contradict the arrest of the morbid process, but merely indicate
the continued presence of the exudation which this has already
caused. In croupous pneumonia the exudation signs may persist
long into well-established convalescence. In catarrhal pneu-
monia, and especially in children, the exudation can not persist
without risk of caseation ; but this is a new process, and its dangers
need not be immediately taken into account in the management
of acute inflammation. Defervescence, therefore, except when
brought on purely symptomatically — as by cold, or large doses of
antipyretics — always indicates at least a temporary arrest of the
morbid process, while the disappearance of many signs of con-
gestion, which in children so often simulate those of exudation,
indicates no convalescence so long as the temperature remains
elevated. A forced defervescence in broncho-pneumonia, apart
from an arrest of the morbid process, would be of little advantage

Indication for Quinine in Pneumonia 429

to the patient, unless in the relatively few cases where a great
excess of temperature threatens or causes convulsions. There
is certainly no danger in children, in non-infectious pneumonia,
of cardiac degeneration from either heat or other cause. The
pneumonias after diphtheria or scarlatina may often owe their
fatal termination to infectious myocarditis, with thrombosis;
but against this danger antipyretics would be powerless. Apart
from the possibility of an infecting agent in the blood, the fever in
pneumonia seems most plausibly explained by paresis of the
heat-regulating centres of the medulla, the consequence of an
excess of excitations conveyed to the medulla from the lungs in
the centripetal fibres of the vagus. According to the experiments
of Rosenbach ^ in normal respiration, the distension of the lung in
complete inspiration irritates the pulmonary fibres of the vagus ;
the irritation is conveyed along these fibres to the medulla, and
inhibits the excitation of the inspiratory centre, which, deter-
mined by the presence of carbonic acid in the blood, has been the
cause of the inspiratory expansion of the thorax. The irritations
thus generated in the lung convert the otherwise permanent
excitation of the inspiratory centre into a rhythmical excitation
by means of periodical interruptions. When the inspiratory
centre is inhibited, the inspiratory movement is arrested, the
thorax passes into the passive state of expiration, and remains
there until the increasing venosity of the blood again excites the
inspiratory centre.

When the pulmonary tissue is inflamed, the fibres of the
vagus suffer an abnormal irritation; the medullary center is
therefore more frequently inhibited; the respiratory move-
ments are shorter and far more frequent than in health. A
sudden acceleration of respiration, with a rise of temperature,
may often suffice to indicate inflammation of the lung tissue,
or the transition from bronchitis to pneumonia, even in the entire
absence of physical signs.

The centripetal nervous irritations which suffice to in-
hibit the respiratory centre and the heat-regulating centres
of the medulla can hardly fail to affect its vaso-motor cen-
tre as well. It seems, indeed, highly probable that the vaso-
motor fibres of the pulmonary blood-vessels, whose independent
existence has not been demonstrated, run in the paths of the

^ Studien iiber den Nervns Vagus, Berlin, 1877,

430 Mary Putnam Jacobi

vagus. But the immediate effect of irritating the vaso-motor
centre is the contraction of blood-vessels. The dilatation of
pulmonary blood-vessels in pneumonia can only be referred
to the vaso-motor system under two circumstances. First, when
the pulmonary congestion is generalized and primary, dependent
on some overpowering influence primarily exercised on the
vaso-motor centre and apart from local pulmonary disease.
Such congestions are seen in malarial and other infections. In
the second case, the long-continued irritation of the vaso-motor
centre, when the periphery of the vagus has been severely
irritated by inflammation of lung tissue, may result in secondary
paresis of the medullary centre, and hence in the terminal con-
gestions of fatal cases of pneumonia.

It is worth noting that two out of the three immediate conse-
quences of vagus irritation in pneumonia are conservative
in their tendency. The increased frequency of respiration
tends to compensate the restriction in area of respiratory tissue,
and this has frequently been pointed out. Irritation of the
vaso-motor centre tends to antagonize the tendency to abnormal
dilatation of blood-vessels caused by the unknown irritament of
the inflammation.

It has not yet been demonstrated that the fever which results
from inhibition of the heat-regulating centres is also conserva-
tive, and only dangerous when in excess, but the other facts
render this a priori probable. Diminution in the area of respira-
tory tissue threatens ultimately a diminution of the oxidations
upon which the vital heat depends. The rise of bodily tempera-
ture caused by deficient elimination of heat — the probable cause
of the fever in at least catarrhal pneumonia — seems to indicate
a blind effort on the part of the organism to husband its heat
resources, and thus to avert the collapse which is threatened by
the disease.

The theoretical estimate of the action of quinine, or of
any medication, in pneumonia mast be based on the manner
in which it can be shown to affect these vagus irritations, or else
the pulmonary lesions which occasion them.

The most usual accounts of the lesions of broncho-pneu-
monia given by English and American writers emphasize the
existence of bronchitis, and then describe the peri-bronchial
alveoli as in a state of catarrhal inflammation, characterized

Indication for Quinine in Pneumonia 431

by a proliferation and desquamation of epithelial cells. Dela-
field/ however, describes hepatized lobules — not granular, as
in croupous pneumonia — yet standing out above the surround-
ing tissue, and filled with epithelium, leucocytes, and fibrin.
This fibrinous exudation, according to Charcot and Grancher —
the French writers who have most recently investigated the sub-
ject— is particularly characteristic of the peribronchial alveoli
at the centre of the lobule. Thus, as Cadet de Gassicourt re-
marks, we may no longer establish a distinction between crou-
pous and catarrhal pneumonia, according to the presence or
absence of fibrin in the exudation.^ This central zone of hepa-
tization, the peribronchial nodule, is surrounded by a zone of
splenization. This is caused by a congestion of the alveolar
walls, or even by a beginning of infiltration of these walls by
embryonic cells, and by a mass of voluminous epithelial cells with
a few leucocytes in the interior of the cells. This zone may be en-
tirely absent, or it may greatly predominate. "It plays an
important r61e in the clinic, for it belongs at once to hyperasmia
and hepatization; it is mobile like the one, and fixed like the
other, and may sometimes extend with great rapidity." ^

The localization of the most severely injured tissue in broncho-
pneumonia, in the immediate vicinity of the inflamed bronchus,
would seem to confirm the old doctrine that the irritament,
instead of being diffused, as in croupous pneumonia, is brought
to the air-cells by the bronchi, or generated among the products
of the inflammation of their mucosa. The condition of the outer
zone of the lobule indicates a more diluted action of the same
irritament, one of whose effects is the formation of leucocytes —
i. e., of pus; the other, the paralysis of the capillaries. The way is
clearly open for the future demonstration of some form of
bacteria which shall have been cultivated in the mucus of
the inflamed bronchial tubes, and secreted the poison that
could produce these characteristic effects. Such a bacterium,
the pneumococcus of Friedlander, is known to have been ac-
cepted by many authorities as the efficient cause of croupous
pneumonia, though Sternberg considers it identical with a
micrococcus existing in the saliva. I am not aware that any

^ Studies in Path. Anat. vol. i, p. 67.

^ Maladies de I'enfance, vol. i, p. 153, Paris, 1 88a

3 Cadet de Gassicourt, /. c, p. 152.

432 Mary Putnam Jacobi

discovery analogous to Friedlander's has been made for broncho-
pneumonia; we must therefore continue to speak of an unknown
irritament as the cause of the vascular and other lesions of the
disease.

In our ignorance of the precise nature of the irritament,
or of the manner in which it determines the pulmonary lesions
of the disease, our therapeutic action must be indirect. It
must aim at maintaining or at restoring the circulation on the
periphery of the inflamed lobules, or of an aggregation of them.
This aim is partly accomplished by the systematic application
of moist heat, and the use of such remedies as seem to modify
the bronchitis, and there is much reason to believe that, for direct
action upon the congested pulmonary blood-vessels, quinine is
the best drug at present known.

I do not propose in this place to review the enormous litera-
ture, experimental, critical, and clinical, which exists on the sub-
ject of quinine. I wish rather to call attention to one theory
of its action which seems to me to have been too much neglected.
I refer to the theory advocated by the Neapolitan writer Chirone,
in an experimental essay published in the Gazette hebdomadaire
for 1875.

Chirone proposed to find some method for reconciling two
current doctrines concerning quinine, each imposingly sup-
ported, yet apparently incompatible with each other. Ac-
cording to one of these doctrines, quinine is a powerful sedative
to the heart and nervous system. According to the other opinion,
and an extensive clinical experience, quinine is a powerful tonic
to both nervous system and heart. It is agreed that these differ-
ent effects are obtained by means of very different doses, being
large in the first case, moderate in the second. Still, it is impor-
tant to ascertain the precise point at which the tonic effect passes
over into the sedative and depressing effect, and the mechanism
by which this may be determined. The phenomenon only
remotely resembles the contrast which is afforded by minute
and average doses of other alkaloids, as morphine.

Experiments on dogs, rabbits, and frogs led Chirone to
the following conclusion :

Quinine increases the diastole of the heart through a direct
molecular action on the muscular fiber, in virtue of which this
actively lengthens and the cavities it incloses become thereby

Indication for Quinine in Pneumonia 433

enlarged. From the increased energy of diastole more blood is
aspired to the heart, and, in order to empty itself, the organ is
compelled to contract more energetically, and thus the systole
is indirectly increased in power. This is the case so long as
the dose of quinine is moderate; the total result, therefore, is
an increased energy of the circulation with consequent tonic
effect.

If the dose of quinine is large, however, the cardiac diastole
comes to predominate too much over the systole; more blood is
aspired into the heart than can be expelled; the ventricular sys-
tole struggles in vain with the load, finally becomes paralyzed by
it, and the heart stands arrested in diastole, with its cavities enor-
mously dilated by blood. In the experiments on dogs, where
the carotid tension was measured by Pick's manometer, the con-
stant tension began to fall after the injection into the jugular of
three doses of quinine of 15 centigrammes each; it soon com-
pletely disappeared. In the experiments on the frog the heart
was exposed and observed for some time, the diameter of the
base measured at the moment of maximum diastole. This, in
one experiment, for instance, was 7.2 millimetres. Eight centi-
grammes of bisulphate were injected under the skin. In three
minutes the heart was observed to dilate very energetically,Tto
become very red. In ten minutes the ventricles were arrested
in diastole, and their base measured 9.3 millimetres. The auri-
cles were still beating. That this diastole was active and not
cadaveric, the author infers from the fact that in thirty minutes
the base measured only 8.6 millimetres and retained this size an
hour later when quite dead. During this diastolic arrest the
heart failed to respond to electricity. But when, in another ex-
periment at the moment of increased diastole, a few drops of a
solution of toad venom were injected, the systole grew gradually
stronger, gained upon the diastole, until after energetic sys-
tolic contractions, in thirty-five minutes, the heart stood arrested
in systole.

The toad venom has the property of stimulating the systolic
contractions of the heart, and its ability to act upon a heart
which is under the influence of quinine proves that this latter
drug has not abolished contractility, but only stimulated the
movement of the cardiac fiber in the direction of its extensility.
The antagonism of the two poisons by means of action upon dif-

434 Mary Putnam Jacobi

ferent mechanisms is analogous to the cardiac antagonism which
exists between muscarine and atropine. I have repeated the
experiment on the frog, with similar results.

A frog at 10.30 received 8 centigrammes of bisulphate and a
second similar dose at 10.41. Just before the injection the heart
was contracting at the rate of 30 beats a minute; the base in
maximum diastole measured 9 millimetres. Within three min-
utes after the injection the cardiac cycles became intensified,
the diastole increased, the systole also energetic, but no longer
rendering the ventricle white. In nine minutes the base diame-
ter had decreased to 8 millimetres. In fifteen minutes the base
had increased in diastole to 11 millimetres; the number of beats
had fallen to 15 in a minute.

In a second frog, previous to the use of quinine the heart
beat at 30 in the minute, becoming completely white in systole;
the maximum diameter of the base measured 7 millimetres.
Eight centigrammes of bisulphate were injected in two doses.
In four minutes the beats had fallen to 24, in eight minutes to
22, and the base measured 9 millimetres. At this time the ven-
tricle exhibited isolated tonic contractions by which it was di-
vided in three parts. A similar observation has been made by
Chirone.

In twelve minutes the heart remained red throughout
systole; the base measured 10 millimetres. In nineteen minutes
the base measured 1 1 millimetres ; the number of beats had fallen
to 16.

It is noteworthy that when monosulphate of quinine dis-
solved in water by means of acid was used, the heart was ar-
rested in diastole in less than five minutes. The effect is here
attributable to the acid rather than to the quinine. Only the
soluble bisulphate is suitable for the experiment.

In addition to the experiments intended to directly measure
the size of the heart in diastole and which I have imitated from
Chirone, I have been able to make others which exhibit the
influence of quinine on the cardiac tracings, obtained by means
of a lever. For this purpose a frog, previously quieted by a
quarter of a milligramme of woorara, was attached to the frog-
plate and the heart exposed. A light lever, composed of a straw
and an exploring disc of pith, reposed on the heart, and regis-
tered its movements on the revolving cylinder. The first trace is

Indication for Quinine in Pneumonia 435

the normal trace of the same frog to which quinine was subse-
quently administered. The pericardium was intact, and on
this account the excursions of the lever are less ample than
in the other tracings. The heart beat thirty times in a minute.
To the same frog was then administered 0.08 centigramme of
bisulphate of quinine, and the first tracing taken ten minutes
later. An immediate and noticeable change took place in the
tracing. The stroke marking the systole of the ventricle is 3
millimetres high and 5 broad, while before the quinine it was 2
millimetres high and 5 broad. The systole therefore is more
energetic, but no more prolonged. The diastole, on the contrary,
is markedly prolonged, being scarcely measurable on the normal
trace, while a perfectly straight line of 3 millimetres in length
measures it on the quinine tracing. The extreme shortness of the
diastole on the pre-quinine trace is not always observed, but
quite the contrary, as may be shown by the other normal trac-
ings taken from another frog. But the peculiar abruptness
of the diastolic line and general appearance of the tracing fol-
lowing quinine was not observed except under its influence.
At the time of this first tracing, ten minutes after the use of
quinine, the heart did not offer the characteristic appearance
that had been previously noticed — that is, the ventricle did not
remain red during systole, but contracted completely, and be-
came entirely white as usual. The number of beats was still
thirty in a minute.

The tracing rate of pulsation and other characters remained
the same for twenty-four minutes from the time of injection.
Then (as shown in the succeeding tracings) when the ventricle
began to remain red during systole, the diastole was markedly
increased, and the character of the tracing changed. The curve
of the systole is the same height — ^3 millimetres — but the ascent
and descent are both gradual instead of so peculiarly abrupt,
and the space occupied is 6 millimetres. The diastolic straight
line has become a rounded curve, whose extremities are 5 milli-
metres apart. The diastole is still shorter in time than the systole,
but it is increasing in energy, as shown by the sinking of the
exploring disc into a airve, instead of a straight line. The rate
of pulsation is only 18 to a minute. A strip of tracing 8 centi-
metres long contains only 9 pulse tracings instead of 17. Nine
minutes later and the height of the ventricular systole trace

436

Mary Putnam Jacobi

reached a maximum of 4 millimetres, while retaining a breadth of
6 millimetres. The duration, therefore, was the same, the
energy still increased; the diastole is a little shortened. In
forty-one minutes after the injection the systolic tracing be-
gins to fall in height ; in fifty-one minutes the systole is markedly
enfeebled and the diastole apparently prolonged, though not
really more so than on the previous tracings.

Trace I. — (a) Tracing of normal frog's heart, taken in
situ; beats, 30; i millig. woorara. {b) Tracing from
another frog's heart.

Trace II. — Cardiac tracing from heart (a) 10 minutes
after hypodermic injection 0.08 bisulphate quinine;
beats, 30; time, 5.12.

Trace III. — Same at 5.22.

Trace IV. — Same at 5.26; 18 beats to minute; heart red
during systole.

Trace V. — Same at 5.35.

Indication for Quinine in Pneumonia 437

Trace VI. — Same at 5.56. Observation ceased.

Tr.\ce VII. — Contractions of normal gastrocnemius of
frog, in Pfluger's myrograph, with stationary cylinder;
weight, 20 grammes; R. A., 220 millimetres; time, 3.40;
height of first 40 contractions, from 15 to 6 millimetres.
Circuit closed by hand.

Trace VIII. — Same at 3.47; 96 contractions obtained in 7
minutes before exhaustion. Rest of I minute included
in this time.

Trace IX. — First contractions gastrocnemius 37 minutes
after hypodermic injection of 0.08 bisulphate quinine;
cylinder stationary; weight, 20 grammes; R. A., 210
millimetres; exhaustion in 2 minutes, after 61 contrac-
tions; height of first 40 contractions, from 10 to 3
millimetres. Circuit closed by hand.

Trace X.

Trace XI.

438 Mary Putnam Jacobi

LiiUJjJjJjjJllllUlL

K. ^j^sjNc

Trace XII. — Same muscle after rest of 9 minutes; ex-
haustion in 2 minutes, after 54 contractions; height of
first 40 contractions, from 10 to 5 millimetres.

In fifty-four minutes the diastolic tracing becomes again
a straight line, but now, for the first time, 6 millimetres in length.
The duration of the systole was now expressed by a space of 5
millimetres, so that the diastole had decidedly gained upon it.

The measurements are the same on the last tracing taken
fifty-eight minutes after the use of quinine. The observation
was then interrupted.

The tracings entirely confirm the inferences drawn from
the direct observation of the heart contracting under the in-
fluence of quinine. They show the increased length and energy
of the diastole, but they show also that this is not a proof of
paralysis; for a considerable time the energy of the systole is
correlatively increased. The diastole finally gains on the systole,
and the heart pauses in diastolic arrest. That the diastole of the
heart is as distinctly active as the systole, has been sustained
with weighty argument by Pettigrew.

"There is every reason," says this physiologist, "to believe that the
movements of the amoeba and the sarcous elements of a muscle are identical.
Both can change their form; elongation in one direction entailing shortening
in another and opposite direction. . . . The movements of the amoeba are
doubtless referable to a centripetal and centrifugal power inhering in the pro-
toplasmic mass which enables the creature to advance or elongate, and with-
draw or shorten, any part of its body. At times the amoeba elongates its entire
body by a wavelike movement, after which it sends out lateral processes which
exactly correspond with the bulgings produced on a muscular fibre when it
is made to contract or shorten under the microscope. . . . The heart differs
from the muscular tubes of the blood-vessels, inasmuch as, when it closes, all
its diameters are shortened; whereas when it expands, all its diameters are
elongated. . . . The fibres and the sarcous particles of the fibres are ar-
ranged vertically, transversely, and obliquely in continuous spirals. . . .
The heart acts as a sucking and propelling organ, in virtue of its centripetal
and centrifugal force. The heart has the power of forcibly expanding itself
as it has of forcibly closing itself .... The centripetal and centrifugal wave
movements pass through the sarcous elements of the different portions of the
heart very much as the wind passes through leaves; its particles are stirred in
rapid succession, but never at exactly the same instant; the heart is moving

Indication for Quinine in Pneumonia 439

This conception which perfectly corresponds to the facts
of muscular action in the heart, the limbs, the hollow viscera,
and the invertebrate animals, furnishes a solid base for the
theory that the increased dilatation of the heart under
the influence of quinine is due to an active stimulation of
the diastole, and not to a commencing paralysis. Accord-
ing to Chirone, the same diastolic action is exerted by qui-
nine upon the arterioles. The administration of quinine to a
rabbit causes a marked hypercemia of the ears, which grow hot,
and after a while begin to pulsate. The same phenomenon is
observed if the auricular nerve, carrying the vaso-motor fibres
of the ear, is divided previously to "the administration of the
quinine. The passive dilatation of the blood-vessels which im-
mediately follows upon this operation is much exceeded by the
active dilatation under the influence of the quinine.

In a small rabbit to whom I gave hypodermically ten grains
of quinine, the blood-vessels of the ears almost, immediately
dilated; in five minutes the animal had an epileptiform convul-
sion; five minutes later a second, which terminated fatally.
In another rabbit the same sudden flushing of the ears occurred five
minutes after a dose of 8 centigrammes, but in twenty minutes
had began to subside. The animal died two hours later.

The action of quinine upon striped muscular fibre resembles
that on the heart and arterial muscles in that it seems to finally
depress the energy of contraction. Thus it is ranked by Brunton
among the muscular depressants. I will not extend this paper
unduly by analyzing this action of quinine, which only remotely
bears upon the effects which here concern us. The accompany-
ing tracings, however, taken from the gastrocnemius of a frog,
excised and placed in Pfluger's myograph, may be interesting
as showing the truth of Brunton's proposition. Traces vii to xii
were taken with a stationary, the others with a revolving cylin-
der. It will be seen that the height of the contractions, as also
the number obtainable before exhaustion, is decidedly less after
the quinine.

When the revolving cylinder was used, the load on the

as a whole, but its particles are only moving at regular and stated intervals,
the periods of repose, there is every reason to believe, greatly exceeding the
periods of activity. . . . The position of rest does not correspond either
to diastole or systole, but to a line midway between both."

440

Mary Putnam Jacobi

muscle was increased from twenty to forty grammes; the dis-
tance of the Du-Bois-Reymond cylinder diminished from 210
to 150 millimetres. The excursions of the lever are enormously
augmented both in the normal and in the quinine muscle and,
about in the same proportion. Their maximum height in the
first is 4I centimetres, in the second 35.

In the normal muscle were obtained sixty-three tracings
of the first kind shown on the paper (traces xiii to xvii), before
the energy of contraction is modified; the quinine muscle only
gives fifty-one.

The normal muscle gave one hundred and forty-seven
contractions before the shape of the tracing was markedly

Trace XIII. — Normal muscle; rotating cylinder; weight,
40 grammes; R. A., 150 millimetres; time, 3.56; shocks
received automatically.

Trace XIV. — Same continued.

Indication for Quinine in Pneumonia 441

Trace XV. — Same continued.

Trace XVI. — Same continued.

modified by prolongation of the descending stroke; but this
occurred after the sixtieth contraction with the quinine muscle
(traces xviii to xxiii). The descent of the lever corresponds to
the relaxation or diastole of the muscle. In the quinine muscle
this diastolic movement begins much earlier and becomes much
more marked than in the normal muscle, though the irritability
of the muscle, as shown by its response to the stimulus, seems
to last as long with as without the quinine, and to be regained
as thoroughly after repose. The slow and ample diastole should
not, therefore, be attributed to paralysis, although the systolic —
the contractile energy, usually so called — be diminished. But the
diastole is directly increased in the voluntary as in the cardiac
muscle. The application of these interesting observations to the
theory of quinine in pneumonia is obvious and, it seems to me,
important.

According to them, the immediate effect of the quinine
would be an increased diastole of the heart, in virtue of which
blood must be more energetically aspired into it and from the

442

Mary Putnam Jacobi

lungs. Simultaneously, but correlatively, the systolic contrac-
tion is increased in energy, tending to drive the blood onward,
in the pulmonary as in the systemic circulation. Thus, in a
double way, an energetic influence is instituted calculated to
dissipate congestion in the lung. This cardiac influence should

WW

)/-

h[\[\I]

/ /

V V

1 I

* 1

I'l/l/vV

Trace XVII. — Same continued at 4.03; total number
contractions in 7 minutes, 147.

Trace XVIII. — Gastrocnemius 30 minutes after 0.08
bisulphate of quinine; rotating cylinder; weight, 40
grammes; R. A., 150 millimetres.

Trace XIX. — Same continued.

Indication for Quinine in Pneumonia 443

Trace XX. — Same continued.

TbaceXXT. — Same continued.

Trace XXII. — Same continued:

v\'\/vwU\/v;V/u

Trace XXIII.— Same continued: total number contrac-
tions, 138.

be re-enforced by a similar increase of active diastole in the ar-
terioles of the lungs themselves, due to a direct action of the
quinine on their muscular fibre, and therefore independent of
complex nerve influences. Without an increase in the energy
with which blood may be drawn through and from the lung, an
increased energy in the propelling force of the heart might

444 Mary Putnam Jacob!

be disastrous rather than beneficial. From the point of view
here developed it becomes clear why the best effects of quinine
should be obtained with relatively moderate doses, rather than
with larger ones. The latter are constantly threatening arrest
of the heart from excess of diastole; to use the classical phrase
consecrated by experience, they tend to depress the heart, and
thus to antagonize the very benefit we hope to gain.

Again, it is clear that this beneficial effect can only be looked
for upon the tissues which are the seat of congestion — the conges-
tion peripheric to the foci of inflammation. But experience
shows that, if this congestion can be limited, the characteristic
morbid process will not extend. The same experience shows that
exudations may remain in the lung without causing fever or
being dangerous, except in so far as they are liable to caseation.
The increased energy of the pulmonary circulation which may
be effected by the quinine tends to arrest this danger, though,
unfortunately, not always successfully. For the numerous con-
siderations which have been alleged, it should follow that a direct
antipyretic effect was not to be looked for in using quinine in
pneumonia, however often high temperatures were observed
to fall after its administration. It is both useless and dangerous
to push the drug for this purpose; far better, if really excessive
temperatures require symptomatic palliation, to effect that with
small doses of antipyrine.

On the other hand, the absence of fever, while signs of
consolidation persist in the lung, do not contraindicate qui-
nine; on the contrary, quinine will often be followed by the
most beneficial effects. These may be seen sometimes in cases
of quite chronic pneumonia, or where, many weeks after asserted
convalescence from a febrile pulmonary affection, a latent
consolidation is discovered as the cause of gastric or nervous
symptoms that had been considered quite inexplicable. Under
the use of the quinine, not only these, but tubular breathing
and percussion dullness may quite disappear.

I think the clinical facts which have been adduced in the
beginning of this section help to bear out the conclusion that
the characteristic indication for the use of quinine in pneumonia
is the dissipation of pidmonary congestion. Theory and experi-
ment indicate that this is primarily effected through an increase
in the diastolic movement of both heart and arterioles. It is

Indication for Quinine in Pneumonia 445

not improbable that the same doses of quinine which do this
also re-inforce the medullary nerve-centers, and enable them to
better resist vagus irritations, and that thus, in a second way,
the drug, though unable to really cure the disease, tends to limit
it, and to arrest the tendency to death. But this large subject
is beyond the scope of the present paper.

CASE OF PROBABLE TUMOR OF THE PONS.'

The child whom I have the honor of bringing before the
Society to-night has the following history.

Jennie Baer, aged ten years. The morbid symptoms are
said to date from two and a half years ago, when the child was
frightened by a trivial incident that she remembered with rather
remarkable tenacity, and describes with lively interest. She was
fastening the apron of a school friend, when the mother of the
latter ran at her, uttering some injurious epithet. The child,
the patient, ran away as fast as she could up several flights of
stairs to her own room, and immediately began to tremble. Two
days later, on going to school, this trembling was noticed by the
teacher. It continued, and even increased for two weeks, at the
end of which time the teacher advised removal from school. She
has never returned, nor attempted any systematic exertion since,
bodily or mental. A little while after the removal from school,
the parents noticed that the child walked as if intoxicated. The
father imitates this mode of walking by slightly swaying the body
from side to side, leaning a little forward, dragging one leg after
another without lifting them from the floor, but somewhat
swinging each in a semicircle, as if to enlarge the base of support.
It is the walk "en fanchant" of the French writers.

At this time, and on account of the trembling and inability to
use the hands for writing or other fine work, the parents con-
sulted Dr. Lilienthal, who diagnosed St. Vitus' dance, and
treated the child accordingly, but without benefit. At this time,
though there was said to be twitchings of the limbs, there was
none of the muscles of the face. The head was, however, habitu-

» Read before the Neurological Society, December 2, 1888. Reprinted
from the Journal 0} Nervous and Mental Diseases, 1889.

446

Case of Probable Tumor of the Pons 447

ally drawn a little to the left side, and the child exhibited the
taciturnity common in chorea.

After this period, i. e., a month or two from the debut of the
accidents, the child seemed constantly tired, and usually spent
the time lying down. She played very little.

At the end of about three months the child began to have
trouble with walking, would frequently stumble, and occasion,
ally fall. Could not go up and down stairs readily. It was at
the same time that she began to grow very fat.

She was brought to my clinic at the Woman's Medical College,
in May of this year, 1888, after two years' continuance of the
above symptoms. She had then been suffering during several
weeks from headache, continuous, diffused, but by no means
violent. It may be noted at this point, that this headache dis-
appeared after a duration of seven or eight weeks, and has not
returned. There had been two attacks of vomiting, at an inter-
val of several weeks. These have not been repeated.

When the child was seen by me in May, I was at once struck
by her large fleshy size, the unusual development of the limbs,
and especially the great size of her head. The measurements
taken at the clinic have been lost ; but a month later, Dr. Peter-
sen kindly made a careful examination of the head for me, and,
together with some other determinations, the following measure-
ments were taken :

Circumference equals 57I centim., or 22|inches.

Naso-occipital line equals 38 centimetres, or 15 inches.

Binauricular line equals 38 centimetres, or 15 inches.

I omit for the moment the other calculations made by Dr.
Petersen.

I could not ascertain whether the mother had been impressed
by the large size of the child's head, or whether she had noticed
that it increased. The habitual expression of the child's face
was apathetic; the eyes heavy and lids drooping; but if spoken to,
her face lighted up and she replied intelligently and with a smile.

There was no hyperaesthesia of the scalp, and percussion of the
head elicited no pain. There was no disturbance of sensibility
of any kind in any part of the face, trunk or limbs. No sign of
paralysis of any cranial nerve. The movements of the upper ex-
tremities were normal, though there was a little clumsiness in the
finer movements of the fingers, as in picking up a pin. There

448 Mary Putnam Jacobi

seemed to be some paresis of the trunk muscles, at all events of
the extensors of the spinal column; for the child avoided sitting
upright, and continually leaned against the back of the chair for
support. The conspicuous disturbance of function was in the
lower extremities. The child could, though with some difficulty,
rise from her chair and stand without support, but only for a
minute or two, for she then fell forward. She could walk a few
steps across the room, but then also would fall forward unless
supported. During the attempt at walking, the body swayed a
little from side to side, and the legs described the semicircular
curves already mentioned. A month later it was noticed that the
right ankle bent while walking, so that the foot turned inward.
This was not perceived in May. At that time the child cotild
walk up stairs more easily than on a level, because she supported
herself by the bannisters. Faradaic sensibility and motility
were intact for all muscles.

The knee-jerk was somewhat exaggerated on both sides.

The visceral functions were all normal ; the appetite was even
excessive. There was no unnatural drowsiness.

A re-examination was made of the case on October 13th.

The condition was found much aggravated in many respects.
The circumference of the head has somewhat enlarged a little.
Having been 57 centimetres, or 22f inches, when measured by
Dr. Petersen in June, it is now 235 inches, a difference of yf of an
inch. The naso-occipital and binauricular measurements re-
main the same.

The general appearance of the child is as already described;
but she has grown still fatter, the girth of trunk, as measured
by her dress which has burst out, being increased at least three
inches.

The intelligence remains clear, notwithstanding the habitual
listlessness. The child describes certain lines drawn on paper as
vertical or horizontal, though she has not heard these terms since
she left school two and a half years ago. She also relates the
story of her original fright, and inquires with interest concerning
the prognosis of her disease.

A new symptom now exists, in the intermittent divergent
strabismus of the right eye. This is occasionally quite marked,
but can always be overcome by voluntary effort, when converg-
ing the eyes to look at an object placed not too near. At a dis-

Case of Probable Tumor of the Pons 449

tance of two feet the nature and number of the objects are ac-
curately distinguished; but when five lines are drawn on a paper,
and the child looks closely at them, she calls them four. If she
attempts to count the lines by placing her fingertip on them one
after the other, the difficulty is increased. In six trials she in-
variably skipped the third line, and could not accurately touch
the fifth. (They were drawn horizontally one above the other.)
This difficulty depended partly on the inability to move the finger
with precision; for it was agitated with slight choreiform move-
ments during the intended act, which delayed its accomplishment,
as is the case in sclerosis. But, in addition, there seemed to be
some visual defect which interfered with the exact guidance of
the finger and which rendered the patient unconscious of the fact
that the finger had been placed above the line instead of on it. I
could detect no diplopia ; but I believe the lines seemed blurred to
the child during the effort of convergence of vision upon very
near and similar objects. This blurring she could not be made
to describe.

There is no evidence of paralysis of the facial. The tongue
protrudes perfectly straight. The uvula is slightly deviated to
the right side. The tonsils are much enlarged.

Thus the only morbid symptoms in the sphere of the cranial
nerves, apart from the optic, are: ist, the intermittent irrita-
tion of the right abducens, as indicated by the intermittent
divergent squint; 2d, the difficulty of converging the eyes upon
near objects, so as to see them without blurring — difficulty ap-
parently due to the relative or positive weakness of the right in-
ternal rectus.

The ophthalmoscopic examination was made later.

Upper Extremities. — The arms are very large; the forearms
do not seem to be disproportionate to the age of the child. All
movements of the arms and forearms can be executed without
perceptible difficulty. Difficulty first appears when the child
attempts to carry a glass of water to her mouth. Left to herself,
she takes this in both hands, as if distrustful of her ability to hold
it in one, although, on being tested, she can do so, and even,
though unsteadily, carry it to her lips. When the glass is held
by both hands against the mouth, she drinks readily until it is half
emptied, but then seems unable to tip the glass at a greater angle
in order to drain it. This movement necessitates the inclination

450 Mary Putnam Jacobi

of the hands on the radial border of the forearms, action effected
by the supinator longus, and the longer and shorter radial ex-
tensors of the wrist. When there is no weight in the hand, the
child can flex and deflect the hand on the radial border of the
wrist; the difficulty only occurs when the hand is carrying a
weight and for a special purpose. There is therefore no actual
paralysis of the muscles, but paresis and diminished power of
co-ordination.

A similar difficulty of co-ordination is shown in the fingers
when the child tries to write. Before the hand reaches the pen it
is agitated with slight choreiform or ataxic movements, as is also
the case when she picks up a pin. She cannot go straight to the
object. She places her head to one side, the rigiit, in order to
guide her hand in writing. She then forms the letters very im-
perfectly, and cannot write them in a straight line. The word
(she resigns the attempt after the first word) always runs ob-
liquely off the page, running up sharply from left to right. It is
to be remembered, in connection with this test, that the child's
education ceased when she Ym.s only eight years old, and before
she had really learned how to write. Apart from efforts at
functional co-ordination, all movements of the fingers can be
performed voluntarily and without distinctly perceptible diminu-
tion of force. The grasp of the hand is normal for a child of her
age. Sensibility is intact for the whole upper extremity.

The faradaic contractility and sensibility are intact.

Trunk. — The child cannot support herself upright, even in a
sitting position, for more than a minute or two, but leans back in
the chair, showing paresis of the spinal extensor muscles.

The thighs and legs are noticeable for their large size, al-
though the apparent muscular enlargement of the four extremi-
ties is not as striking as is that of the thorax and abdomen.
While sitting, the child can extend the legs on the thighs per-
fectly, but not vigorously, and can flex, extend, and adduct the
feet and toes. Abduction is extremely feeble on both sides.
Nevertheless, she is unable to support herself standing for more
than a half minute, and cannot now walk at all unless supported.
With support she walks, dragging and to some extent swinging
round the legs, while both ankles bend under her, bringing the
feet into exaggerated varus. Thus there has been marked de-
terioration in the functional power of the limbs since May, and

Case of Probable Tumor of the Pons 451

even since June, when the special weakness of the peroneal was
first observed, and then only on the right side.

There is no retraction of the gastrocnemii muscles. The child
has never walked on the toes, nor never exhibited the special
phenomenon of pushing back the thighs or of climbing up them
in rising. Nor was there ever lordosis, but the trunk always fell
forward.

In May, as already stated, the child did pull herself up stairs
by the aid of her arms. Also, while she was yet able to walk un-
supported, the body did sway from one side to the other, as if
from alternate inclination of the pelvis, and the legs spread out-
wards to enlarge the base of support. These symptoms have now
disappeared, as the paresis has increased so far that the child can-
not even attempt to walk unsupported.

The absence of retraction in the gastrocnemii is paralleled by
similar conditions throughout the limbs, where neither con-
tracture nor deformity exists. The sensibility is intact. All the
muscles contract to the faradaic current, but the peroneal muscles
demand a stronger current than the other. Thus the quadriceps
extensors contract at 300 millimetres of the induction coil, the
peroneal not under 260. The knee-jerk is moderately exag-
gerated. No ankle clonus can be obtained.

The limbs are constantly cold, subjectively and to palpation.

In addition to the foregoing symptoms may be noted:

That the child suffers no pain in any part of the body, nor has
ever done so except for a moderate headache in last spring.

There is neither nausea, vomiting, nor anorexia, but, on the
contrary, an excessive appetite, bordering on bulimia. There is
occasional sighing respiration.

There is no constipation, but a condition of the bowels ap-
proaching incontinence, inasmuch as the child is unable to re-
strain the impulse for evacuation when this makes itself felt;
and the impulse always occurs after any mental excitement, as if
she has been laughing. The control of the bladder is similarly
imperfect.

On the 28th of October Dr. C. S. Bull kindly made an ophthal-
moscopic examination of the child. He found choked disk in
both eyes, outlines much blurred, veins swollen and tortuous,
arteries narrowed and in some places disappeared; process begin-
ning to recede, but leaving an atrophy of nerves, which is now

452 Mary Putnam Jacobi

incipient, but tending to increase. Acuity of vision much dimin-
ished, only iVo- Spasm of right abducens. He diagnosed a
descending inflammatory process of the optic nerve.

In 1887 Dr. Hun, of Albany, presented the following case,
completed by the autopsy, to the American Neurological Asso-
ciation :

Gliomatous hypertrophy of the pons.

Female, set. 6; father died a little more than a year after she
was born, with symptoms of melancholia and dementia.

For several years left leg has tired easily; left foot shows a
tendency to turn in; wore rubber straps; otherwise excellent
health until two months ago, when attack of croup and cough.
Pain felt in head with each cough. Three weeks before coming
under observation the patient began to walk badly, and seemed
to have trouble in balancing herself while walking. She had an
excessive appetite and vomited a little at times.

When first seen the patient was a well-nourished, intelligent
girl, but with a vacant expression. Her speech was drawling.
Her head was drawn towards the right shoulder most of the time,
especially if she made any exertion. She stood with her feet
wide apart, and was careful not to lose her balance. In walking,
her right leg was more rigid than her left, so that she took freer
and longer steps with her left leg, and therefore in walking tended
to go in a circle, turning always to the right. Her walk re-
sembled that of a drunken person. The movements of the arms,
especially of the right, were very awkward, but she held them in
no fixed position.

There was no disturbance of sensibility in any part of the face,
body, or extremities, and she recognized objects placed in her
hands when her eyes were shut.

The plantar reflexes were normal. The knee-jerk was ex-
aggerated, especially on the right side. There was no ankle
clonus.

On ophthalmoscopic examination, well marked optic neuritis
was found in both eyes. Urine contained neither albumen nor
sugar.

The patient was first seen on the 17th of April, and from this
time the symptom^ rapidly increase, passing through gradations
I need not here describe, until a fatal termination was reached on
the 13th of June.

Case of Probable Tumor of the Pons 453

At the autopsy, the pons varolii was found enlarged to three
or four times its normal size, and on section, it was found to have
been replaced by a tumor, apparently a glioma, which so well
preserved the normal appearance of the part that it looked like a
greatly hypertrophied pons.

On microscopical examination, the nervous elements of the
pons were found to be encroached upon, infiltrated, and in some
places destroyed by a great accumulation of small cells. The
proliferation of cells was not limited to the pons, but extended
throughout the crura cerebri and medulla, and especially in the
roof of the aqueductus Sylvii. The prevailing character of
the cells was spindle, but there was a considerable number of
spheroidal cells, both large and small.

The bones of the skull were thin. The subarachnoid fluid
increased. The cerebral convolutions flattened, and the cerebral
substance very oedematous. Lateral ventricles greatly dilated,
and filled with fluid of normal appearance.

Dr. Hun ascribes the inco-ordination of movements to pres-
sure upon the transverse fibres of the pons, and the origin of the
crura cerebelli ; the absence of absolute paralysis to the fact that
the nerve elements were compressed but not destroyed by the infil-
tration. He explains the absence of sensory disturbance by a
greater resistance of sensory function, even when sensory fibres
are submitted to the same pressure as motor fibres. He notes
that the tumor in its growth produced no symptoms of irritation,
that there were no convulsions, and but little headache.

In all these circumstances, the case closely resembles the one
I now present. Other points of resemblance are the long dura-
tion of slight muscular inco-ordination, and even paresis of the
lower extremities, without other symptoms, up to a certain date;
then the rapid deterioration in a few months; the fact that the
most marked paresis was shown by the turning in of the right
ankle; the exaggeration of the knee-jerk, the other reflexes re-
maining normal; the vacant expression of face, and apathetic
appearance, although the memory and intelligence were entirely
preserved; the indistinctness of articulation: the optic neuritis,
the slight and transitory squint, which in Dr. Hun's case was
convergent, in this one divergent and unilateral, without paralysis
of any ocular muscle ; finally, the excessive appetite and excellent
preservation of nutrition. The nutrition in our case is even

454 Mary Putnam Jacobi

exaggerated, so as at one time to have suggested a general
lipomatosis.^

The optic neuritis is, as well known, a most important in-
dication of intra cerebral tumor; and indeed* I did not permit
myself to make a positive diagnosis until the existence of this
symptom had been established. B ram well enumerates the fol-
lowing diseases other than mental in which double optic neuritis
may occur. It is nearly always present in lead encephalopathy ;
it is not uncommon in meningitis and cerebral abscess; and it
may occur in Bright 's disease. It has occasionally been asso-
ciated with uterine derangements, hypermetropia and anaemia,
which, when complicated with hysterical symptoms, may be
easily mistaken for cases of intra cranial tumor.

In our case all the foregoing conditions may be readily ex-
cluded.

Stephen Mackenzie has published in the second volimie of
Brain, a case where an optic neuritis depended upon a diffused
cerebritis, resulting in general atrophy of the brain, and an in-
flammation extending down the optic nerve. The symptoms of
this remarkable case, which has often been quoted, are chiefly to
be referred to the cortex of the brain, and in no wise resembled
those of this child.

When I first saw the patient, the unusually large size of the
head, the apathetic expression of face, the moderate degree of
motor disturbance, the diffused nature of the symptoms, led me
to suspect an hypertrophy of the brain, due to diffuse lobar
sclerosis, "In such cases," observes Gowers, "the symptoms
have been very similar to those of cerebral ttmaor, headache,
vomiting, local palsy, convulsions."^

"The symptoms," observes Schmidt,^ "of diffused sclerosis of
the brain are gradually increasing muscular weakness, manifest-
ing itself especially in the lower extremities, giving rise to an un-
steady, stumbling gait and frequent falling. There are also epilep-
tic spasms, constant or intermittent attacks of headache, vertigo,
tinnitus aurium, photophobia, dimness of sight with dilatation of

' A case of tumor of the pons and medulla in a child of two years, related by
Hobson, (Brain, Vol. IV., p. 531), differed greatly from ours, especially in the
number of cerebral nerves involved.

' Diseases nervous system.

' Pepper's Archives of Medicine.

Case of Probable Tumor of the Pons 455

the pupil, blunting general sensation without anaesthesia. The
skull may be enlarged and thinned."

So Richardiere^ affirms: "Convulsions and attacks of tremor
and muscular rigidity are never absent in cases of diffused sclero-
sis." Both these symptoms have been entirely lacking in the
case of Jennie Baer. On this account the hypothesis of the dif-
fuse sclerosis was finally rejected.

To sum up : the reasons for diagnosing an intracranial tumor
in the case of the child before you, are: ist. A diffused motor dis-
turbance, beginning as inco-ordination and difficulty of equi-
librium, increasing at first slowly, then with sudden rapidity to
such paresis of the lower extremities as renders station impossible ;
of the trunk muscles, as renders upright sitting difficult; of the
upper extremities, as interferes with the more delicate movements
of the hands. 2d. Preservation of faradaic contractility, ab-
sence of nutritive lesion of the paretic muscles. 3d. Gradual en-
largement of the head. 4th. Moderate apathy of expression and
dulling of intelligence. 5th. Spasm of right external rectus.
6th. Double optic neuritis, commencing atrophy of the optic
nerves, marked diminution of visual acuity.

The circumstances which indicate a localization of the ttrnior
in the pons are: ist. The absence of convulsions, a negative
fact of great importance, and frequently observed in slowly in-
filtrating tumors of the pons. 2d. Absence of marked or defi-
nite symptoms, and of monoplegic spasm or paralysis, tend to
exclude tumors of the cortex. 3d. Absence of hemiplegia ex-
cludes the basal iganglia. 4th. The same, with absence of symp-
toms in the sphere of the motor oculi, excludes tumors of the
crura or base of the brain. 5th. Absence of headache, nystag-
mus and vomiting, and the development of motor paralysis in
addition to the original motor inco-ordination, excludes, I think,
the cerebellum. 6th. The general march of the symptoms, the
bilateral character of the paresis, the inco-ordination, even the
absence of anaesthesia or pain, are precisely what have been ob-
served in slow growing tumors of the pons. In seven out of
thirty cases of pontine tumor tabulated by Bernhardt, no dis-
turbance of sensibility existed but headache, and even this failed
in two cases, as also in that of Dr. Hun. The irritation of the
right abducens, the only cranial nerve at present affected except
' Scleroses encephaliques primitives de I'enf ranee. Paris, 1885.

456 Mary Putnam Jacobi

the optic, is in accordance with a localization of disease in the
pons. The excessive appetite of the child is a symptom probably
to be referred to the medulla.

Characteristic symptoms of pontine tumors which are as yet
absent, are: ist. Alternate paralysis of face and limbs. 2d.
Paralysis of the hypoglossus, or of any cranial nerve, other than
the optic. 3d. Marked difficulty of deglution or articulation.
Some defect of the latter function is, however, noticeable, and
there is occasionally sighing respiration. The tumor could hardly
be situated in the upper region of the pons, or there would be
motor oculi symptoms, or others referring to the corpora quad-
rigemina; while at the lowest portion of the pons, the spinal
accessory nucleus or the hypoglossal nerve should be involved.
We may infer that the growth is situated about the middle
region, that it is bilateral, that it is below and anterior to the
nucleus of the fifth and anterior to the nucleus of the seventh
nerve. That on this account the lower extremities are paralyzed
before the upper, and the seventh has so far escaped. We must
further infer that the lesion consists of a very gradual infiltration
of elements, gliomatous or sarcomatous into the nerve tissue, and
is not a sharply defined new growth, forcibly compressing any
localized bundles of nerve fibres.

One other hypothesis remains,^ namely that there is a timior
of the cerebellum which presses on the pons. The reasons which
militate against this hypothesis are, that there have never existed
any characteristic symptoms of cerebellar tumor, except the tot-
tering walk and loss of equilibration. But these symptoms are
also observed in the infiltrations of the pons which affect the
transverse crura cerebelli.

In the four cases of cerebellar disease reported by Dr. Seguin, ^
the following symptoms, positive and negative, were observed,
differing from the history of Jenny Baer.

Case I. — Positive: Headache, nystagmus, convulsion. Nega-
tive: Absence paralysis until after hsemorrhagic seizure two
months before death.

Case II. — Positive: Vomiting, violent headache, convul-
sions.

» This was strongly urged by Dr. Sachs at the meeting of the Neurological
Society when the above communication was read.

' Journal Nervous and Mental Disease, vol. xiv., April, 1887.

Case of Probable Tumor of the Pons 457

Case III. — Diffused headache, vomiting, double exophthal-
mus, absence paralysia.

Case IV. — Repeated nausea and vomiting, severe occipital
headache, absence paralysis.

The paralysis in the case of Jenny Baer is not indeed complete
but it is sufficient in the lower extremities to render standing
quite impossible which is more extensive than is ever the case
with purely cerebellar timiors.

THE PRACTICAL STUDY OF BIOLOGY.^

Remarks addressed to the Massachusetts Medical Society at its Annual
Dinner June 12, 1889.

The 1 08th Annual Meeting of The Massachusetts Medical
Society, Boston, June 11-12, 1889.

Doctor James B. Chadwick presiding "where the white
spread tables made a handsome picture and where Baldwin's
Orchestra had already begun to enliven the occasion." Doctor
Chadwick introduced Doctor Mary Putnam Jacobi as "one
whose life had been spent in pursuing the most abstruse subjects
in medical science."

Doctor Jacobi spoke on the practical study of biology.

Mr. Chairman,

In accepting the very great honor of an invitation to be a
guest at the annual meeting of the Massachusetts State Medical
Society, I did not expect to be called upon to speak before it. But
since, Sir, you have chosen to still further honor me by calling
upon me, it would be churlish to refuse.

In a meeting like this, I presume it is intended that each
person present shall bring forward the thought or thoughts that
may have especially preoccupied him or her during the year that
has gone by. Now, one of the subjects which has especially
preoccupied me is one that I think must interest everybody
who is either a student or a physician or a director of medical
education. I refer to the question of the practical study of biol-
ogy, in its threefold aspect of normal physiology, of pathology,
and of elementary therapeutics.

There is a strange idea current among the laity, and even

' Reprinted from the Boston Medical and SurgicalJournal, 1889, Vol. 120,
page 63 1.

458

The Practical Study of Biology 459

among physicians, that the study of physiology by means of
practical experiments and demonstrations on the living subject
is only necessary, and indeed only permissible for purposes of
occasional original research. You know that this is the view-
taken by so august, yet in the premises so incompetent a body
as the English Parliament, which has assumed the right and duty
of actually forbidding physiological experimentation for any
other purpose. But in reality the necessity is not occasional, but
permanent, and coextensive with the education of every medical
student. For what are the facts of the case? We undertake to
prepare ourselves and others for the most profound and subtle
and difficult of all sciences, the Science of Life; we undertake
this, not for the purpose of irresponsible contemplation, but with
the avowed intention of practically intervening among the phe-
nomena of life, of regulating disturbances in the mechanisms of
living organisms, of bringing normal order out of what may have
become the wildest disorder and confusion. Now, how is it
possible to do this unless the mind has first become thoroughly
and personally acquainted with the normal order? Students in
other natural sciences than animal physiology know perfectly
well that listening to a didactic lecture or conning the pages of
a text-book are entirely insufficient means to bring the mind
into fertile contact with nature. Such contact cannot be ob-
tained second-hand, but only by those who, as Claude Bernard
says, have in the hospital, the amphitheatre, and laboratory,
with their own hands stirred the soil foetid and palpitating with
life. The difference is enormous between the person whose
knowledge of physiological phenomena is summed up in a list
of verbal statements, and the other whose mind has become
saturated with vivid conceptions of vital facts, based upon
multiple experience of them. No one who has not tried it, knows
how indefinitely both intellect and senses gain in delicacy and
subtlety when they have become habituated by practical inter-
course with the endless intricacies of nature. And it is the
peculiarity of medical work that the necessity for such mental
subtlety is not confined to the few, to the elite, to the college
professors who, very likely, have withdrawn from the practice
of medicine. The poorest sick person in the hospital, the most
tedious invalid of the private clientUe, serve to illustrate all the
mysteries of the science, and demand on the part of their doctor

46o Mary Putnam Jacobi

the ability to cope with its deepest and most difficult problems.
The physician whose thought is sufficiently elevated, and whose
imagination is sufficiently keen, confronts this commonplace
sick human body as an antique priest may have stood before the
veiled mysteries of Iris. It is his privilege, and to an increasing
extent, to draw aside the veil of the surface, to plunge his eye into
the depths of the organs and tissues as they are actually at work,
to follow in imagination the innumerable streams of vital actions
which are eddying and swirling in every direction, and to try, out
of the dizzying maze, to construct a truthful chart of the vital
conditions and tendencies of the organism. If he cannot do this,
or attempt to do it, if he has not been previously trained to a
profound feeling for the complexity and intricacy of vital pro-
cesses, he is liable to lay heavy and clumsy hands upon them,
and to estimate them according to theories both coarse and
crude. When he gives a medicine he simply "exhibits" it. He
has no distinct conception of a train of vital events, among
which he is to insert some new and deliberately contrived con-
ditions, by means of which the direction of the whole series may
be modified. This is the ideal formula for physiological thera-
peutics. It is far enough from being realized or realizable
to-day ; but it seems to me no one can doubt that it is ultimately
destined to supplant the rule of traditional "Secundum artem,"
with which at present we must too often be content.

It would be indeed the merest pedantry to attempt to base
existing therapeutics exclusively upon existing physiological
knowledge. No practising physician can or would follow Her-
man's classification of remedies, when he places first the utterly
useless oxide of carbon because we know all about it, and con-
signs to a limbo of doubt opium and quinine as drugs of which
we know little or nothing. Whether we know or not, we are
compelled to use them. But it is absurd to say that we know
nothing because we do not know analytically. We do possess
an accumulated amount of experience in regard to these priceless
remedies which is of immense and scientific value, although the
ultimate reasons for their action have not yet been demonstrated.
But on this very account, and because an exact and quantitative
formula cannot be given for the action of drugs, we are obliged
to intrust their handling to the acquired tact of long practice.
Now tact, mental or physical, can only be acquired by incessant

The Practical Study of Biology 461

and varied experience in the practical operations requiring the
exercise of tact. How can be acquired the mental tact needed to
unravel the complexity of vital phenomena as they unravel
before us in the history of every sick person? how can be learned
the tact needed to undertake the direction of these phenomena,
except by previously prolonged study of vital phenomena in the
simpler animal body free from disease?

If it be admitted that the dead body must be dissected, as
was still practically denied less than a hundred years ago; if
it allowed that the lesions left by disease must be studied in
autopsies, which are still often refused in obedience to the gross-
est superstitions; if it be conceded that medical students must
have some clinical experience with the sick before they are
allowed to graduate, concession which still often remains a
paper right, — it equally follows that the same persons must
study living organisms in the only way in which they can be
studied, by analyzing, dissecting, and handling them in the
process of life. There is no need now of wading through the
horrors of physical pain amidst which Magendie laid the founda-
tions of modern science. The use of anaesthetics obviates the
objections on the score of cruelty for this as for other forms of
surgical operation ; and it is certainly one of the most extraordin-
ary demonstrations of modern science that life can be so dissected
and dismembered and yet persist.

The kernel of the question lies just here. Knowledge of the
living organism, for practical purposes, must be obtained practi-
cally. Indeed, no knowledge is ever obtained in any other way,
but only a verbal imitation of knowledge. The physician who
has not learned to adjust himself to the intricate delicacies and
fragilities of living organisms by laboratory study, is condemned
to take his first lessons in dealing with life upon human beings.
He is compelled, therefore, to experiment upon subjects who are
often, if not always, far more valuable than the frogs and rabbits
of the laboratory.

Sooner or later, if he is to be successful, his whole mind must
have become modified in that mysterious manner in which the
minds of students of nature do become changed, as they seem
insensibly to blend with the phenomena they can profoundly
contemplate. But the question is, shall this necessary training
come sooner, or later? Shall it come economically, or with

462 Mary Putnam Jacobi

tremendous though carefully concealed expenditure of human
life? Whether we will it or no, all practising physicians are con-
stantly and professionally engaged in physiological experimenta-
tion, are trying the most audacious of experiments, — trying,
namely, to deliberately modify the course of human life. Is it not
evident, therefore, that we should strive to the utmost to obtain
the most real and profound visions of life before we venture on
our attempts at interference?

I should like, Mr. Chairman, to mention an incident that
occurred to myself in the course of a very simple laboratory
experiment. I was examining the circulation of a frog's lung
by means of the Holmgren apparatus. I happened to so focus
my lens that all the outlines of the capillaries and blood corpus-
cles disappeared, leaving visible only the spaces between the
epithelial cells. Nevertheless there remained a vision of the
streaming movement of the invisible blood through the ramified
spaces. The streaming was so rapid, so energetic, so ceaseless,
it seemed as if it were pure motion or force divorced from the
accidents of matter. The microscopic shred of tissue from the
insignificant animal seemed for the moment to give a glimpse
of a mighty vision of endless life, streaming with infinite energy
into the minutest particles of an infinite universe. The impres-
sion was indescribably powerful. Since then I have confronted
new students with this same impression, for the purpose of throw-
ing open at once the horizons towards which they were henceforth
to keep their eyes directed. And this is what it seems to me all
students in medicine should learn to do.

HYSTERICAL FEVER '

Read at the Neurological Section of the Academy of Medicine, April,

1890.

Case M. M. — The illness to be described began on July 226.
last, 1889, when the patient entered the New York Infirmary.
But in the preceding year, winter of 1 887-1 888, she had suffered
from a succession of disorders, to which reference must be made
on account of their bearing on the illness in question.

In December, 1887, the patient was seized with a pain in the
chest, unaccompanied by fever, but which was diagnosed
pleurisy by the first physician consulted. His diagnosis had
greatly alarmed the patient. As, however, my own examina-
tion of the chest failed to discover any physical sign of pleu-
risy, I interpreted the pain as a pleurodynia. After this diagnosis,
the pain rapidly subsided; but a paresis of the bladder, which
had already showed itself, deepened to a complete paralysis
and retention of urine. Catheterism was performed for some
time, but the trouble finally yielded to strychnine and local
faradization. There appeared severe pain in the left ovarian
region, attended with fever. The temperature rose and fell
irregularly through the day, occasionally going as high as 103°,
more often reaching no higher maximum than 102°. Physical
examination of the pelvic organs failed to discover any objective
sign of local imflammation, and the disease finally subsided. Be-
fore the patient had left her room, however, she was attacked with
a severe catarrhal sore throat, attended with abundant dif-
fuse mucous exudation, but not truly diphtheritic. This
was in March. After recovery and resumption of ordinary
occupations, the patient became subject to intermenstrual

' Reprinted from the Journal of Nervous and Mental Diseases, 1890.

463

464 Mary Putnam Jacobi

metrorrhagia, for which no uterine cause could be ascer-
tained, and which was referred to one of the obscure forms
of functional ovarian irritation. During the summer of the
same year (1888), the patient suffered from a bilateral partial
paralysis of the lower extremities, especially affecting the peroneal
muscles. She remained able to move her limbs in bed, but was
quite unable to stand or walk. She recovered this power, how-
ever, when provided with braces which supported the ankles
and reaching to the knees. She then went to the seashore, and
for two or three months was perfectly well. On returning to
the city and becoming involved in much mental worry and anx-
iety, her physical troubles returned. There were first, attacks
of retention of urine and metrorrhagia; then almost entire
inability to use the eyes in reading, which a competent oculist
explained by simultaneous paresis of several external ocular
muscles. He referred this, moreover to an attack of diphtheria
which had been experienced five years before; but I think this
was improbable, as, until the period which I have just de-
scribed, the use of the eyes had been attended by no
difficulty. It seems to me that the paresis was of an hysterical
nature and analogous to that of the peroneal muscles, which
had deprived the patient for a time of the power of walking.
This opinion was subsequently also expressed by Dr. Putnam,
of Boston. The ocular defect persisted through the winter.
Twice during this time the patient was seized with an attack of
severe pain in the abdomen, which, after lasting twenty-four
hours, at once lost its acuity and rapidly subsided, when I had
assured her with great positiveness that she did not have peri-
tonitis. Once, after receipt of an agitating letter, she became
apparently delirious and unable to speak for twelve hours.
This was immediately followed by an intense dysphagia, over-
come at last by a combination of moral force and local fara-
dization. In the following summer, 1889, the patient's health was
considerably improved. She engaged in some occupation
involving considerable fatigue — I think teaching in a public
night-school — and at once began to lose ground again. Early
in July, diuing the second day of a menstrual period, she ac-
companied a friend on an excursion to Bedloe's Island, and
climbed the stairs within the statue. The menstrual flow was
immediately arrested, and severe pain appeared in the left

Hysterical Fever

465

ovarian region. On the 226. of July she was admitted to the
New York Infirmary, and on the 23d had a temperature of 102",
and the next day of 103°. The fever persisted at about this range
till the 13th of August, when, after two days of normal tempera-
ture, it rose once more to 103°, and thence fell to a range between
98** and 101.5°, which it maintained till the middle of September.
During this time I did not see the patient, as I was absent from

Aug

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the city. The physicians in charge had only a very slight ac-
quaintance with the previous history of the patient, and she
herself gave an imperfect and rather misleading account of her
series of illness. On account of the fever, the abdominal pain was
explained by some focus of parametritis, but it was noted that
the pelvic examination — made, it is true, with reserve on account
of the acuity of the accidents — always failed to detect any evi-
dence of inflammatory exudation.

On my return in the middle of September, the patient was
in about the same condition as at the beginning of the attack,
and quite the same as in the middle of August, after the fever
had fallen to a low grade. Upon hearing the history and com-
bining it with that of the many and varied attacks which I had
previously and minutely observed, I ventured to express the
positive opinion that on this occasion also no really inflamma-
tory process had ever existed, but that the accidents were
nervous, and initiated by an ovarian irritation, the latter due to

466 Mary Putnam Jacobi

the arrest of menstruation by an unwonted physical exertion
which involved the nerves of the lower extremities, i.e., of the
lumbar plexus, which also innervates, to a great extent, the
ovary. It seemed probable that the menstrual arrest had left
a congestion of the ovarian cortex, or even that minute hemor-
rhages had occurred there. The patient was put under ether, and
a most thorough pelvic examination made, both by myself
and by Dr. Cushier, with a completely negative result. Dr.
Cushier admitted that the entire absence of any trace of exuda-
tion at this time, though some irregular low fever persisted and
the abdominal pain was as severe as ever, rendered it altogether
improbable that a parametritis had ever occurred.

With the concurrence of Drs. Cushier and Kilham, there-
fore, I positively assured the patient that she had no pelvic
inflammation, that the attack was of the same nature as the
others in which I had previously attended her; that she could
safely get up from bed as soon as she pleased; and that a few
applications of galvanism to the abdomen over the seat of the
pain would rapidly dissipate it.

The applications were, in fact, made with the positive
electrode over the ovarian region of the abdomen, the nega-
tive over the lumbar spine. Each application entirely removed
the pain for many hours. But it seems probable that the moral
effect of the diagnosis was quite as important, so rapidly did
the patient change her attitude and so soon was she able to
get out of the bed on which she had been lying for two months.
In a week she was walking about ; in ten days was entirely free
from pain. The temperature remained normal from the day
of the examination under ether.

Before the modern researches upon fever as the result of
poisonous material circulating in the blood, the conception
of a purely "nervous fever" was an entirely familiar one. In-
deed the abdominal typhus, which is now recognized as a typical
example of infectious disease, was considered, not so very long
ago, as a "nervous fever," and liable to be produced by causes
which greatly fatigued or exhausted the nervous system.

The well-known urethral fever was an admitted case of
a purely nervous fever of reflex origin. "Febrile movements"
of all kinds were easily explained by varying functional irritations
of the nervous system, among which were not reckoned irrita-

Hysterical Fever 467

ments conveyed to nerve centres in the blood nourishing them.
Indeed, even the fever of inflammation was referred to the peri-
pheric irritation of the nerves of the inflamed tissues; and not
until much later was it suggested that some materies morhi was
carried from the focus of inflammation to the central nervous
system.

To-day, however, the point of view has so radically changed,
that it is easy to forget that all the modern explanations of
fever simply increase the list of irritaments to which the pyro-
genic apparatus of the nervous system is susceptible. Although
there be, as there undoubtedly is, increased production of heat
during fever, it is established that this would not cause a rise of
body temperature unless the elimination of heat were simul-
taneously deranged absolutely or relatively. But this derange-
ment in the elimination of heat depends upon disorder of the
heat-regulating apparatus of medullary and cerebral centres,
which thus react to the influence of the chemical poisons gener-
ated by inflammation or infection. There is, therefore, no essen-
tial contradiction between the new and old views about fever.
An exclusively nervous cause is always plausible, because
the proximate cause of increased body heat is always to be
sought in the nervous system.

Before the thermometer was supposed to enable us to dif-
ferentiate with precision between inflammatory and non-inflam-
matory pain, the liability of hysteria to simulate inflammations,
and especially those of the abdominal cavity, was one of the
well-worn themes of text-books. "Hysterical Peritonitis"
is a classical chapter in every dissertation on hysteria, and in
every guide to differential diagnosis in abdominal disease. But
I think that to-day — and the case I have related shows it — we
are liable sometimes to be misled by an habitual, though legiti-
mate, reliance on the thermometer as a means of differentiation.
It is easy to decide in the absence of fever that pelvic pain
must depend upon some other cause than inflammation; and
in the great majority of cases this conclusion is confirmed by
the absence of all physical signs of exudation. Yet Dr. Thomas
and some other gynecologists declare that an extensive pelvic
exudation may be formed, and with considerable rapidity,
without the slightest rise of temperature ever being produced.
However this may be — and I confess never to have myself seen

468 Mary Putnam Jacobi

the statement proved — the two attacks of pseudo-parametritis
attended by fever, which were sustained by the highly hysterical
patient under discussion this evening, serve to illustrate the
converse proposition, namely, that a rise of temperature may
occur under circumstances strongly suggestive of pelvic in-
flammation and yet all positive proof of true inflammation be
entirely lacking.

Hysterical fever has lately received much attention from
both English and French physicians. In 1883 Pinard wrote
a thesis on the pseudo-fever of hysterics, in which he claimed
to show that hysterical fever did not really exist: — that is,
in the cases described: either no thermometrical observation
had been taken, or the thermometer registered a temperature
not above 38° C, while often the temperature remained normal.
The pseudo-fever consisted, therefore, in an assemblage of
symptoms which simulated fever, but were not truly febrile.
Among these was conspicuous the acceleration of the pulse,
phenomenon essentially analogous to the tachycardia of ex-
ophthalmic goitre. The patients oftenfhad subjective sensations
of heat, also severe headache and coated tongue. This condition
was not unfrequently regularly paroxysmal, so as to simulate
attacks of malarial fever, but was entirely uncontrolled by
quinine.

In a more recent thesis, passed by Henri Fabre in 1888,
the existence of a true fever, and even hyperpyrexia of really
hysterical origin, is, however, formally reasserted. Cases are
related where such fever was accompanied by functional dis-
turbance of various organs, so as to simulate respectively men-
ingitis, peritonitis, or pneumonia. Intermittent fever and ty-
phoid fever are also said to be simulated. The same assertion
is made by an American physician, Bressler, in a communica-
tion to the Medical Record, for 1888. This writer relates no
cases in detail, and I do not think that his diagnosis is absolutely
proved by his descriptions.

"By hysterical fever," says Dr. Bressler, "I mean a per-
verted condition of the nervous system, occurring in a neurotic
individual, attended by an elevated temperature, which may
last from a few hours to several days, and is associated through-
out its duration with symptoms of an hysterical character."
"This fever," continues the writer, "generally begins with

Hysterical Fever 469

symptoms simulating a mild intermittent — chilliness, loss of
appetite, constipation, or occasional diarrhoea; tongue coated,
headache, general malaise, rise of temperature, face flushed
generally, or in a circumscribed spot on the cheeks, eyes clear
and brilliant, mind bright, comprehension quickened. There
is general muscular and cutaneous hypercesthesia. The special
senses are more acute; there is no true delirium. The stomach
is excessively irritable, and vomiting very persistent. The
abdomen is extremely sensitive to pressure, and peritonitis
may be simulated, but may be excluded by the fluctuating
character of the pains, the absence of tympanitis, and the de-
velopment of ovarian pain under pressure. The tempera-
ture varies from ioi° to 105° F., and the maximum is reached
early in the attack."

In the Transactions of the London Clinical Society, Dr. Hale
White related the following case: A girl of eighteen was ad-
mitted to the ward, on the loth of August, for a febrile attack,
which lasted four days, and then subsided. On September 8th
she was suddenly taken ill with a severe pain in the left side,
and was readmitted to the hospital the next day. The patient
could hardly walk, and was somewhat incoherent in speech.
Within the course of twelve hours the pain was located in four
different places — the left iliac region, the epigastrium, the lum-
bar region, the splenic region. The attention of the patient was
easily diverted by conversation, and she then permitted con-
siderable pressure over the seat of the pain. The temperature
was at first 103°; on September loth, after a chill, rose to 105°,
to fall in the evening to 99°. On the i ith, at 6 a.m., the tempera-
ture was 98.6°, at 6 p.m. 104°; September 12th the temperature
did not rise till evening, when it was 102° at 6 and 98.8'' at 10.

In the analysis of the case Dr. White excluded all other
causes of either the pain or the fever except hysteria. But
it is noticeable that the patient vomited on two successive
days, and during the previous brief illness in August there
had also been symptoms of a gastro-duodenal catarrh. It
seems to me that such an organic condition really existed,
and was the immediate cause of the neurotic condition upon
which the wandering pains, and markedly irregular fever,
directly depended.

Dr. White remarks that, although several cases of hys-

470 Mary Putnam Jacobi

terical pyrexia have lately been recorded, much skepticism
has been expressed in regard to it. Among these recorded
cases is one by Clemrow, in the Medical Press and Circular,
of 1887. A laundrymaid, of twenty -three, was admitted to the
Edinburgh Royal Infirmary, October 22d, with dizziness, pain
in the left side, and a purpuric rash over the lower extremities.
On the 29th of November the patient had a severe fright, and
her temperature rose to 107.8°. After this the records of tem-
perature are so extraordinary as to suggest fraud, were it not
that there was no way in which a fraud could have been effective.
At midnight of the same day three successive records, taken at
short intervals, read 111°, 108°, 98°. On November 30th the
temperature in the right axilla was 108°; the left, at the same time,
99.4°. At midnight the temperature was 98° on the right side
and 108° on the left. Similar local maxima, varying from hour
to hour, were observed on the ist, 2d, and 3d of December;
after which the records are not given. On November 30th the
patient had several spasms simulating tetanus, probably hysteri-
cal opisthotonos. On December ist, together with headache
and nausea, there was a peculiar rhythmical movement of the
eyelids, alternate elevation and depression. There was left
internal strabismus, and sluggish reaction to the light of the right
pupil. Throbbing pain at the vertex increased by pressure. On
December 3d there were frequent spasms, with muffled heart-
sounds; pulse at the wrist imperceptible. On December 4th
the patient became delirious, and continued so until the 13th.
The plantar and patellar reflexes were both absent; there was
cutaneous anaesthesia, incontinence of urine and fasces. After
the 13th these symptoms disappeared, and the patient began
slowly to improve. But she was not fully recovered until April.

Clemrow considered the hyperpyrexias to have been local,
and not extending throughout the body.

In the Lancet, for 1879, Donkin related the case of a girl
of nineteen, who, during convalescence from a mild typhoid
fever, had, at frequent intervals, temperatures of 108° or 110°.
These were of short duration, and unaccompanied by other
symptoms than a sensation of heat.

In another case, observed by the same writer, from the
20th of May to the 20th of June the temperature every morning
and evening varied between 101.8° and 106.8°.

Hysterical Fever 471

Donkin quotes similar cases from Creig Smith, Cliffe, and
Meade. The last, like Donkin's own case, was also a girl con-
valescent from typhoid, whose temperature for a month kept
incessantly varying from 103° to 109°, sometimes in fifteen
minutes would run up to 111°. In these English cases the tem-
perature was always taken in the axilla.

In the Gazette Hebdomadaire, for 1886, Debove describes
a patient who, every day for a month and without other symp-
tom, presented morning and evening a temperature of 39.5" C.
This was in November. In December the temperature rose to
40**, on the 17th of January was 41.4°, and on the 25th reached
a final maximum of 414°. After this it slowly fell, and became
normal on the 30th. During this period of three months the
morning and evening temperatures were almost always alike:
occasionally one or the other was higher by one-tenth or two-
tenths of a degree. This prolonged hyperpyrexia resulted in no
emaciation or loss of strength.

In 1886 Barie described a case (also in Gazette Hebdoma-
daire), a severely hysterical young woman, servant at Bic^tre.
She was subject to frequent convulsive attacks, transient pa-
ralyses, profound disorders of sensibility. One morning, after a
violent convulsion, she became completely hemiplegic, on the
left side, except the face, as regarded both mobility and sensi-
bility. After this she had thirty convulsive attacks in the course
of twelve days. Sometimes for two or three days together she
would remain in a state of complete mutism, without eating
and also without urinating. All remedial measures failed, and
the physician contented himself with simple observation. One
morning, after a violent convulsive attack, the temperature in
the axilla was found to be 39° C. From this time, for twenty
days, there was permanent fever, as measured both in the axilla
and rectum. Evening temperature was usually higher than morn-
ing by some tenths of a degree, but on five days the mornmg
temperature was the highest. There was no functional dis-
turbance, and the tongue remained moist. The fever was
highest on the days of the attacks, but persisted on the other days
also. On the twentieth day sudden defervescence occurred, the
patient remaining otherwise the same, neither better nor
worse.

In the "Periscope" of the Journal of Nervous and Mental

472 Mary Putnam Jacobi

Disease, for February, 1890, is described a case of hysterical
pseudo-phthisis where, during three days, the temperature
varied from 103° to 104° F.; on the fourth day it rose to 113",
and the patient became slightly delirious. In an hour the tem-
perature fell to IDS'*; in the evening was 106.3°. On the next
day it again rose to 113°, but fell in an hour to 99.5°. During
the next few days the temperature varied from 101.3° to 103.1°,
and then became normal. The symptoms had begun with an
attack of hasmoptysis, which was followed by severe dyspnoea,
cyanosis, and apparently threatened asphyxia several times
during the night. During the next two months the same group
of symptoms was repeated several times with complete absence
of physical signs of phthisis. There was retention of urine.

The most interesting cases quoted in the thesis of Henri
Fabre are two, of simulated meningitis, one of apparently
severe pulmonary disease. The first of these, a young woman
of twenty-four, who had previously suffered from chorea and
nervous aphonia, was admitted to the hospital with a tem-
perature of 39.5° C. Her face was swollen and congested,
eyes closed on account of an intense photophobia. The head
was retracted completely, cephalalgia violent, insomnia and
cries, abdomen retracted, constipation absolute, meningitic
streak easily developed, severe generalized hyperaesthesia, knee-
jerk little modified, no morbid condition discoverable in lungs,
heart, or kidneys. During ten days the patient remained in
about the same condition: prostrated, eyebrows contracted,
pupils contracted but equal, five or six times bilious vomiting
without effort (having all the appearance of cerebral vomiting).
A diagnosis was made of tubercular meningitis, and (but with
little hope of doing any good) leeches were applied behind the
ears and calomel administered. On the tenth day the patient
was found sleeping naturally, and, on being aroused, ceased
to complain of the pain in her head. The temperature had
fallen to 38° C. In a few days more the patient was fully con-
valescent, but on first getting up was affected by a transient
paraplegia.

The history of the second case closely resembled the first.

I have myself seen a similar case in the service of Comil
at La Charite, and, curiously enough, the same patient re-
turned, a year later, with the same group of symptoms, and

Hysterical Fever 473

her personality being recognized, the diagnosis was the second
time at once correctly made.

The case of febrile hysteric dyspnoea related by Fabre is
as follows: The patient was a woman of twenty-six; admitted
to the hospital with an evening temperature of 39° C. and a
dyspnoea of five or six days' duration. There were thirty-five
to forty respirations a minute, but unaccompanied by trace
of cyanosis. The most careful auscultation failed to discover
any lesion of either lungs or heart, and the absence of albuminuria
was held to exclude a ureemic origin to the dyspnoea. The fever
continued for twenty days, being extremely irregular, with
occasional intermissions of normal temperature, followed by a
rise to 39° or 40° or over. On the twentieth day occurred an
abrupt defervescence, and at the same time the dyspnoea ceased.

The recognition of hysterical fever as a distinct clinical
affection has been much facilitated by recent researches on
the relations of the cerebro-spinal nerve-centres to the tem-
peratures (general or local) of the body. As every one knows,
these researches were initiated by the famous observation of
Sir Benjamin Brodie, on a rise of temperature in a few hours
to 111° F., in a patient who had sustained a fracture of the
spine, with traumatic section of the cord. This observation
was published in the Medico-Chirurgical Transactions in 1837.

The researches of Tscheschin, in 1866, are equally famous
and well known. In some respects they seem in contradiction
with Brodie's clinical observation: for when, in animals, this
experimenter cut the spinal cord below the medulla, the tem-
perature of the body fell; but if the section were made between
the medulla and the pons, the temperature rose excessively.

The more exact experiments of Horatio Wood, in his beauti-
ful researches on fever, published in 1880, demonstrated that
when the spinal cord was cut anywhere between the level of
the third and second cervical vertebra there was at first an
enormous increase of heat-dissipation, correlative with the
general vaso-motor paralysis; that in forty-eight hours this was
followed by a diminution in the dissipation of heat, but also a
diminution in heat-production, so that, as had been before
observed, the net result was a fall of body temperature. Wood
also observed the rise of temperature consecutive to section of
the cord between the medulla and pons. He accepts the in-

474 Mary Putnam Jacobi

ference drawn from the facts by Tscheschin, that there exists
in the medulla some nerve centre or centres whose influence tends
to stimulate the production of heat in the thermo-genetic tissues,
namely, the muscles; that this influence is habitually restrained
by that moderating centres in the pons or above it, and that the
rise of temperature observed in the last experiment is due to the
withdrawal of this moderating influence from the real heat cen-
tres. More recent experiments have extended the field of experi-
ment and inquiry. Eulenburg and Landois showed that excita-
tion of one cerebral hemisphere is followed by a local rise of
temperature of the limbs of the opposite side. These experi-
menters made no observations on the general temperature.
In 1884, Charles Richet (Compt. Rend. Societe Biol., 22 Mars,
1884) pricked one cerebral hemisphere of a rabbit with a steel
pen which perforated the cranium, and found in the course of
two hours that the rectal temperature rose from 39.5° C. to 40.4°.
The next day, when the temperature had fallen to 39.2°, a nerve
pricking caused a rise to 42.8°. The animal died in the night,
presumably of the hyperpyrexia, as no brain lesions were dis-
covered to explain the death. It was found that the pin had
penetrated to a spot situated three or four millimetres in front
of the corpus striatum.

A little later, Schreiber' found that a rise of temperature
occurred after lesion of any part of the pons, of the cerebral
peduncles, cerebrum or cerebellum, provided the animal oper-
ated on were protected from the radiation of heat by wrapping
in cotton wool. In 1885, Aronsohn and Sachs in Germany,
and Dr. Isaac Ott in America, began almost simultaneously,
but quite independently of each other, to search for heat-regu-
lating centres in the brain. The German observers^ trepanned
rabbits at the juncture of the sagittal and coronal sutures,
and entered the brain with a needle, three millimetres broad,
at a point about one millimetre outside the longitudinal sinus.
A carbolized dressing was immediately applied, and the well-
being of the animals seemed to remain undisturbed.

When the operation was performed on the cerebrtun anterior
to the Rolandic convolutions, no effect on the temperature was
observed. But the punctures which passed to the base of the
brain, from the point of junction of the coronal and sagittal

' Pfiuger's Archiv., viii., S. 576. 'Pfluger's Archiv.,iS85.

Hysterical Fever 475

sutures were always followed by an enormous rise of tempera-
ture. If the puncture only penetrated the cortex cerebri, no
effect on temperature was produced. Electrical irritation of the
susceptible region, i.e., the tissue just in front or on the outer
side of the corpus striatum, also caused a rise of temperature.
An increased excretion of nit:ogen was observed during this
artificial fever, so an increased heat-production was inferred,
but no calometrical observations were made.

These difficult observations were, however, made by Ott,^
and add greatly to the value of his experiments on the brain.

Ott established four localities at the base of the brain whose
puncture, and consequent irritation, was followed by a rise
of body temperature. These were, at a point just within the
anterior part of the corpus striatum; a second point between
the corpus striatum and the thalamus; a third at the anterior
part of the thalamus; and a fourth at the point of decussation
of motor fibres at the nib of the calamus in the medulla. In
the fever consecutive to irritation of these centres, there is at
first an increase of both heat -production and heat-dissipation
but both soon fall below normal, though fever continues. In
addition to these centres, however, Ott discovered two others
on the cortex; one at the point of juncture of the supra sylvian
and post sylvian fissure; the other in the neighborhood of the
cruciate sulcus, i.e., over the Rolandic convolutions.

When either of these cortical centres were irritated, tem-
perature was depressed. If, on the other hand, they were re-
moved by slicing and subsequent washing with carbolized
water, the temperature rose.

From the total result of his experiments, Ott infers that
the basal centres, like those of the spinal cord, habitually stimu-
late the production of heat; are thermogenetic centres. But
those of the cortex, the sylvian and cruciate, habitually restrain
the activity of these lower centres, and may therefore be called
thermotaxic.

Under certain circumstances the striate and extra striate
centres may also be thermotaxic, and moderate the spinal
centres below them. They have, therefore, a mixed character
or function.

Girard^ confirmed the results of Ott's experiments on the

' Journal Mental Disease, 1888. ^Archives oj Physiol, 1886 and 1888.

476 Mary Putnam Jacobi

corpus striatum, and also observed a rise of temperature to
follow punctures at various localities in the posterior part
of the brain, but none when these were made anteriorly. The
fever was attended by increased elimination of nitrogen in
the urine, and was controlled by antipyrine. Rise of tempera-
ture was also induced by faradising the striated bodies for half
an hour with needles insulated to their tips.

Horatio Wood, also, in thirteen out of fourteen experi-
ments, found that localized destructions of tissue just behind
the crucial sulcus, thus compromising Hitzig's region, were
followed by a rise of temperature and decided increase of heat-
production.

A curious confirmation of the foregoing observations is
offered by Zawadowski,' who found that antipyrine ceases
to reduce temperature if administered after section of the
spinal cord at the atlas, an operation which removes the inhibi-
tory influence of the brain from the thermogenetic centres of the
cord.

The interest of the foregoing observations is very great
in their bearing on the general theory of fever. In accord-
ance with them, all fever can finally be ascribed to derange-
ment of the central nervous apparatus, which controls the
generation of heat in the muscles, the latter being the ultimate
thermogenetic apparatus. Hence, the striking fact, that the
cerebral centres so far established as regulating the production
of heat, are chiefly situated on the motor tracts, namely the
Rolandic convolutions, the striate centres, and the medulla.

In zymotic fever the thermogenetic centres would be irri-
tated by the poison circulating in the blood; in traumatic,
perhaps also in inflammatory fever, the same result is produced
by irritation of peripheric nerves; in hysteria there would be
paralysis of the cortical thermotaxic inhibitory centres rather
than excitation of the basal thermogenetic centres.^ Reflex
fevers, like urethral and worm fever, might be supposed to imply
on the other hand direct irritation of the thermogenetic centres.

This paralysis would then enter into the entire series of
hysterical phenomena, which depend upon loss of cortical
control over lower centres. It becomes analogous to the loss
of cortical control over subcortical vaso-motor centres, upon

» Centralblatt f. medicim-wissen, 1888. ^ W. Hall White, loc. cit.

Hysterical Fever 477

which Meynert has so strongly insisted, and nevertheless it is
not to be resolved into a vaso-motor phenomenon. For it has
been shown, especially in some experiments of Wood's, that the
vaso-motor medullary centres are not affected in these artificial
fevers, and respond as usual to an irritation of the sciatic nerve.

A danger attends the recognition of any group of clinical
symptoms as hysterical. It is the danger of ascribing to hysteria,
symptoms which are really caused by organic disease. This
is even more serious than the opposite error of interpreting as
the result of organic disease, symptoms really due to hysteria.
The diagnosis is, therefore, always important, and often delicate
and difficult. It would be impracticable in this place to analyze
the elements of diagnosis in regard to each case which might be
simulated. But this may always be remembered: Exclusion of
the grave organic lesion which ma}'- be simulated, does not neces-
sarily exclude the origin of the disorder in some lesser lesion,
which may even entirely disappear, while the storm which has
been aroused continues. The type of such a sequence is offered
by the prolonged hysterical neuralgias which may originate in a
sHght sprain (traumatic hysteria).

In the case which forms the basis of this paper, I think
it is not at all improbable that the last series of accidents origi-
nated in a slight hemorrhage into the cortex of the ovary, oc-
curring at the time of the arrested menstruation. A permanent
ovarian irritation or irritability existed, manifested by the per-
sistent recurrence of menorrhagias, in the absence of all uterine
disease. It seems as if this would be sufficient to explain the
entire series of phenomena, itself being an expression of a grave
hysterical diathesis.

MODERN FEMALE INVALIDISM.^

In the course of the preparation of the Shattuck Lecture for
1895, on "The New England Invahd," recently published in the
Journal, its author, Dr. R. T. Edes, obtained a letter from Dr.
Mary Putnam Jacobi, which by his and her permission we print.
The letter was not originally prepared for publication. Criti-
cisms might perhaps be made upon it as to its details, but as a
whole it is very interesting and suggestive, and we commend it
to our readers.

Hotel San Marko, St. Augustine, Fla.

Dr. Robert T. Edes. Dear Sir: — Dr. Morton handed me your letter
to her some two or thrfee weeks ago, asking me to comment on it. I do not
know that my comments will be of any use; still, as Dr. Morton asked me to
do so, I will offer a few suggestions.

In the first place, it seems to me that this entire question needs to be dealt
with on a much larger scale, and from a more anthropologic standpoint than
is usually the case. Impairment of reproductive function through disease, or
imperfect development of the reproductive organs, is a race fact of the greatest
importance; and much evidently depends on quite a combination of conditions.
To assume, as good old Miss Beecher did, that all the troubles connected
with reproductive organs can be explained by the habit of wearing many
petticoats, is to rely upon a most superficial and inadequate . explanation.
Miss Beecher suggested, as a remedy for the evil, a hoop shirt, which actually
and by independent agency came into fashion a few years later; but I doubt,
if it greatly changed the conditions Miss BeecheSr was considering.

In the most general sense, and apart from specific infections and mechani-
cal injury, utero-ovarian disease is evidently traceable to imperfect develop-
ment; and it cannot be denied that this is alarmingly prevalent among Ameri-
can, and especially among New England girls. But I think it is putting the
cart before the horse to assert that this imperfect development of the repro-
ductive organs and corresponding nerve centres, is due to over-stimulus,
over-education of the intellectual centres.

The first question to ask is. Why are the latter centres in such a state of

' Reprinted from the Boston Medical and Surgical Journal, 1895.

478

Modern Female Invalidism 479

activity, that they spontaneously demand opportunities for greater exercise,
or eagerly respond to the systematic education, which for the first time in the
history of the world, is offered to masses of girls?

My own answer would be complex. In the first place, it seems to me
that reproductive failure, or rather the relative degree of it which is observed,
and which is shown is amenorrhea, dysmenorrhea, the ovaro-metritis of men-
strual subinvolution, in sterility after the birth of one child, that these phenom-
ena are fundamentally phenomena of acclimation. On that very account they
should be more conspicuous in New England, whose rigorous climate differs
from that of Old England than does the climate of the Middle States. In
the South and West the influence of malaria replaces the influence of a colder
climate.

I am immediately reminded that the climate of Canada is more rigorous
than that of New England; yet both French and English Canadians are re-
markable for fertility, and I think are much less subject to uterine disease.

It is evident, therefore, that other elements come in to complicate one that
always exists to some extent unless counteracted, when a race is transplanted
to a foreign climate, as the English in India. The second condition I would
refer to the special circumstances of the settlement of New England. For
a hundred years there were conditions of peculiar hardships; and the present
inhabitants are in many cases the descendents of those who during that
first century struggled at once with cold, poor food, confinement to mean
houses for two-thirds of the year, epidemic disease (small-pox) the normally
depressive influence of constant apprehension from the Indians, and constant
gloom from a religion as ferocious as the character of the Indian enemy.

In Canada during this same century, there was relatively little settlement
by families who left descendants; it was colonization by monks and nuns
and soldiers; and the half-breed illicit progeny of the latter had one ancestral
foot well planted in the soil. The real colonization of Canada began in the next
century, when conditions of life were beginning to be easier. On the other
hand — and here is a curiously cross influence, which I think we must take
into account — increasing care of life means diminished infant mortality and
a constant survival of individuals wi,th a debility which, though sheltered
during childhood, manifests itself irresistibly during adolescence. The powers
of life, sustained for the more or less adequate fulfilment of individual func-
tions, flag in reproduction nutrition; the wave ebbs from its outermost expan-
sion. Another cross influence comes in here, which is almost paradoxical:
namely, that people of exceptional longevity are now known not to transmit
as much vigor to offspring as do those of only average strength. Hence, only
those who survived exceptionally severe conditions, such as surrounded the
early New England colonists, may be presumed, like the people who to-day
live to eighty and over, to have absorbed or consumed the nutritive forces of
the organism in the interest of individual functions; leaving less for the "sup-
plementary waves" of reproductive nutrition, and less for the offspring
developed in these.

How often does every physician receive in his consulting office frail
girls brought by robust mothers, wno cannot understand this fragility when
they themselves have never been ill in their lives? This is the converse of

48o Mary Putnam Jacobi

what is also seen in the robust sons of sick mothers who seem to have absorbed
the strength of the parent stem. The influence of tubercular inheritance is
especially important both in the development of uterine disease, of the anemia
which often precedes this, and of the neuroses which may either precede,
originate or replace this. I think cervical catarrh in young girls, with passive
pelvic congestions and uterine displacements from relaxation of ligaments
and of the pelvic floor, may almost invariably be traced to a tubercular
family diathesis as it frequently precedes tubercular disease in the individual.

Tubercular disease makes a premier etape of degeneration, that which gives
a susceptibility to an external agent; hence is less profound than the spon-
taneous degenerations of the grave neuroses. Yet how many of the latter
also, at their inception, merely imply a susceptibility to physiological or other
irritants and would be averted were the nature of these better understood !

I believe that ovarian disease on the other hand, though always originating
in some degree of fundal endometritis, whenever it assumes marked prominence
or independence, is always rooted in a neurotic diathesis rather than in a
tubercular. Many of the nervous or even mental disorders often assigned to
"reflex ovarian irritation" are the direct expression of cerebral disease or
cerebral malnutrition, which also causes the vaso-motor paresis in the vascular
territory of the ovaries; at least, this is my explanation.

Here, again, the individuals who would in former generations have died
of tubercular disease in infancy or early adolescence are preserved by a better
hygiene, therapeutics or climatic adjustments, to mature life, but on penalty of
suffering from uterine disease excited either by celibacy or childbirth.

And, again, it was not necessary to wait for Grasset to show (as in his essay
on "Tuberculosis and Hysteria"') that the neuropathic constitution in itself
is often a transformed tubercular diathesis.

The wide prevalence of consumption in New England, due to climate, to
poor food, and to imperfect acclimation among ancestors, is certainly a very
important source of uterine disease, and attendant or equivalent neuroses in
the present generation.

I believe it is also true that the imperfect development of reproductive
organs, nerve centres, and correlatively of sexual instincts, is one reason that
the intellectual life of women, and the cerebral cortex, has in the present
generation become more active. To suppose that cerebral activity could
dwarf sexual activity (which is often alleged) is absurd, or rather, though
theoretically conceivable, is in contradiction with known facts. The one fact,
now noted by ethnologists, that sexual passion is far more highly developed
among highly civilized peoples than among savages, shows that normally the
two poles of existence develop pari passu and not in antagonism to each other.
Detailed proof could easily be furnished were it necessary.

But until now, women have not held a normal position as complete human
beings; their mental activity, though often considerable has been spontaneous,
vmtrained, unsubjected to systematic educational drill. I think the flagging
of reproductive activities, due to temporary impairment of race vitality, has
facilitated this extraordinary new departure in the regime of the race, whereby

'Brain, 1880.

Modern Female Invalidism 481

the sex whose brain has been hitherto neglected, is to-day educated, stimulated
often unfortunately forced.

But because this new departure is a race innovation, it undoubtedly in-
volves difficulties and dangers, risks a certain dislocation of organic adjust-
ment, which can only be gradually triumphed over. It requires the most
careful study of individual cases, and recollection of three facts. First, that
the girls already in possession of the most active, responsive and readily edu-
catable brains, may be essentially deficient in general organic force, and es-
pecially as manifested in the reproductive organs, hence unprovided with the
undercurrent of sexual strength which is needed to healthfully support cerebral
activities. Second, that the other girls — and there are to-day not a few of this
class — who are not only mentally active but seem physically sound and strong,
may not have the final reproductive strength; their menstrual life is healthy,
but they may either break down in child-bearing or have delicate children.
Third, that the reproductive imperfection in question may show itself at first by
no more tangible symptoms than moral incapacity for love or marriage, or fan-
tastic perversity of sentiment in regard to these fundamental interests, this
incapacity frequently involving or determining social situations that react
most disastrously upon the health of the "highly strung " individual.

With all these race and constitutional complications, when educational
systems are adopted which not only ignore such general considerations but
violate the most elementary principles of ordinary hygiene; when brains which
are not only immature but female, and whose stock of inherited capacity for
traired work has all been derived from the parent of the opposite sex; when
such brains are submitted to an often illogical cramming; when foodMs inade-
quate and exercise absolutely neglected; when hours of work are imposed
which no adult woman would bear, and few men ; when all this work is carried
on under the stimulus of high-pressure competition, emulation, vanity, some-
times fear; when hundreds of girls are shut up together in the exciting atmos-
phere of a college life, so that their nerves are mutually reacting on each other,
— under all these circumstances it is not at all wonderful that towards the close
of adolescence so many girls exhibit constitutional debility and uterine disease.

It must, however, be noted, and contrary to what might theoretically be ex-
pected, that the influence of superior education, although occasionally seem-
ing to be detrimental, is far less so than any other observed agency. Where
there is to be trouble, this is always distinctly foreshadowed at or before
the ages of sixteen, seventeen, eighteen, when the college education begins.
My own statistics, as collected in the essay on "Rest in Menstruation," and
also those which have since been collected by college alumns, all show that the
least ill-health is found among the women who have been most highly educated.
Of course, the fact partly shows that only healthy girls complete their course
and graduate; others fall away earlier. At all events, the college-bred women
are still so much in the minority that the general statistics are hardly affected
by them; yet physicians often write as if these constituted the mass of nervous
invalids.

But the list of causes of the special invalidism of the century is not yet
ended. Every city physician who has also seen country people must have
noticed that while mechanical injuries from childbirth are rather more com-

482 Mary Putnam Jacobi

mon among country people, their influence is apt to remain limited to mechani-
cal discomfort. But a much less degree of injury in city women excites, or
is liable to excite, a protean swarm of nervous disorders. The French comment
emphatically on this contrast between the Parisian and peasant women. Evi-
dently this implies more delicately strung nervous organization, in more unsta-
ble equilibrium, as more developed among the inhabitants of cities, or specifically
among the women who have been freed from manual labor. I think Tolstoi is
quite right in asserting that such freiedom is a curse to the "upper classes."

If the excessive drudgery of New England ancestors under unfavorable con-
ditions weakened the constitution of their descendants, the excessive luxury
of these descendants is certainly a second cause of weakness. I am not speak-
ing now of coarse and unreasonable luxury, but of the refined and delicate
ease of life and sensibility in which so many thousands now contrive to live —
up to a certain point an advantage and a grace, beyond this a dangerous
effeminacy. In manual drudgery, or in Puritan asceticism, there are dangers
from exhaustion, depression, or gloom; but there is at least a discipline, an
enforced stoicism, which is of immense value in bearing toil, trouble or shock.
To-day stoicism has vanished from education, as asceticism from creeds; it is
considered natural and almost laudable to break down under all conceivable
varieties of strain — a winter dissipation, a houseful of servants, a quarrel with
a female friend, not to speak of more legitimate reasons.

Women who expect to go to bed at every menstrual period expect to
collapse if by chance they find themselves on their feet for a few hours during
such a crisis. Constantly considering their nerves, urged to consider them by
well-intentioned but short-sighted advisers, they pretty soon become nothing
but bundles of nerves. They suffer from lack of the wholesome neglect to
which their grandmothers were habitually consigned; too much attention is
paid to women as objects, while yet they remain in too many cases insuffi-
ciently prepared to act as independent subjects. A healthy objectivity is one
of the greatest desiderata for modern women. To knock the nonsense out of
them, to direct attention from self, to substitute a cosmic horizon for that of
their own feelings, who does not know the importance of this for thousands
of hysterical women? and equally the impossibility of attaining it?

I think, finally, it is in the increased attention paid to women, and especially
in their new function as lucrative patients, scarcely imagined a hundred years
ago, that we find explanation of much ill-health among women, freshly dis-
covered to-day, but which always excited, and which is often due to conditions
arising among men, and not therefore new. Shattered nervous systems
are inherited by girls from the alcoholism of the fathers; gonorrhea contracted
by wives from husbands; sterility due to licentiousness in which the innocent
woman may have no share; enforced celibacy due to bad^social arrangements;
occasionally, though less and less frequently, childbirths too close together;
certainly all these causes of ill-health to women have existed for centuries.
I think the peculiarity of the present time is that now attention is being drawn
to the special effects produced upon women by these general causes. All of
which is respectfully submitted.

Very truly yours,

Mary Putnam Jacobi.

A SUGGESTION IN REGARD TO SUGGESTIVE THERA-
PEUTICS.^

Notwithstanding the number of elaborate and ingenious
theories which we now possess in regard to the phenomena of
hypnotism, every medical discussion on the subject seems to re-
veal the absence of sufficiently definite formulae for practical
medical guidance. Neurologists will often state that they have
hypnotized every patient in their wards for a while in order to see
what would come of it ; and when nothing came of it, they aband-
oned the method. This way of experimenting resembles that
practised some thirty years ago in the Paris hospitals by Briquet.
To ascertain the therapeutic value of large doses of quinine, he
gave thirty or forty grains to every patient in his service. Notic-
ing, after this medication, that such patients as were at the time
lucky enough to be suffering from acute inflammatory rheuma-
tism were improved, he assumed that large doses of quinine
were a specific for acute rheumatism. And so they continued
to be until later they were displaced by the salicylates. Without
discussing in detail the ntmierous reports of already recorded
cases, and without submitting to a fresh analysis, the already
so often scrutinized rival doctrines of Charcot, Bernheim, Heiden-
hain, Myers, and others, we may, I think, from consideration of
generally accepted facts, formulate this precise statement:

Hypnotic suggestion acts upon specific cases of either pain or
disability which depend upon morbidly persistent organic memo-
ries of pain or disability. It is now generally conceded that mem-
ory is a general property of organic tissue, in virtue of which any
event or series of events which has once occurred among its
elements tends to reproduce itself indefinitely until interrupted

' Reprinted from The New York Medical Journal, 1898,

483

484 Mary Putnam Jacobi

by some new influence. From this point of view, organic mem-
ory constitutes one mode of the still more general property
of matter which we call inertia.

In organisms possessed of nerve centres this general rudi-
mentary tissue memory becomes complicated by a special circum-
stance. This is, that the events which transpire in the general
somatic tissues excite secondary events in the nerve centres,
because, by means of the nerve filaments connecting the periph-
ery with the centre, an impression made upon the former is
transmitted to the latter, is in a manner perceived by the latter.
This secondary impression constitutes a record of the organic
event, and when it is made upon the brain cortex of human
beings or even of the higher mammals, becomes what is especially
known as memory.

Where, as in human beings, there are two systems of nerves,
the cerebro-spinal of voluntary life and the sympathetic system
for the vegetative life, the recorded memories of the former
are so predominant and important that those of the latter fall
entirely in the background.

The evidence of the record is extremely indistinct, because
it does not rise into active consciousness. No neuromuscular
action passes unperceived unless through mental preoccupation
with other things. But all normal visceral processes do so habit-
ually. Moreover, in numerous cases degenerative or malignant
disease may, unperceived, effect extensive structural ravages in
organs hidden from view, because the disease fails to excite the
pain which is alleged to be Nature's warning signal of danger. If
it be so, her sentinel often sleeps on his post, and even more
often cries "Wolf ! " with all the mendacity of the boy in the fable.
The so-called conservative function of pain may have been
present as such in the original intention of Nature ; but in actual
fact, this intention is woefully overlaid and distorted, as in so
much else of the good dame's blunderings.^

If, as I believe to be the case, hypnotic suggestion acts spe-
cifically upon the memories of events recorded in or by the brain
cortex, the relative obscurity of the record for visceral and nutri-
tive processes would be a reason to greatly limit the efficacy of

» Facts like these recall the bold speculation of C. S. Peirce, that the realm
of Law is not coextensive with the universe, but only extends over a certain,
however large, area, beyond which is Chance.

Suggestive Therapeutics 485

the method in regard to these. Experience shows, indeed, that
hypnotism is not often efficacious in trophic disorders. On the
other hand, there are a few cases, apparently well authenticated,
where visible trophic lesions, like ulcers, have yielded to hypnotic
suggestion. This is sufficient to show that the nutritive events
which have led to the lesion have been recorded in the brain,
and may therefore possibly be reversed by an influence exercised
directly upon the brain and subsequently emanating from it.

The most interesting field for hypnotic therapeutics is admit-
tedly that offered by the sphere of animal life. The most de-
finite application is to cases of pain or of some specific functional
disability, which have originated in an individual morbid occasion
whose efforts by good rights should have disappeared with the
cessation of their cause, but which have, on the contrary,
persisted.

A typical case is the persistent pain of hysterical joints, initi-
ated by a sprain, but capable of lasting months after all symp-
toms of the sprain have subsided. I do not think we are much
helped by calling such pains imaginary, or by saying that they
"illustrate the influence of the mind over the body."

But let us look at it in another way, and instead of talking
about the mind, which perceives or feels the pain, consider the
brain, which records the event that has transpired within the
cerebro-spinal sphere. In any case, and for the person with the
most healthy nervous system the brain record will be made, for
the accident can be remembered. But in the healthy person the
sensory impression rapidly fades out of consciousness, out of
memory, and only the accessory circumstances are retained.
The injured person remembers the fact that he had sprained his
foot, but he ceases to remember how he felt when he did it, and
can not by any effort reproduce the conscious sensation. To use
a customary terminology, the sensation sinks out of his supra-
liminal consciousness and falls back into the subliminal conscious-
ness; it ceases to be a part of his present existence, and becomes
only an item of his past experience. But as his total personality
is made up of his present and past experience taken together, it
may be said that no sensation once experienced is ever entirely
lost. Normally, the past experience is submerged by the present,
which is, perhaps, equivalent to saying that when fresh intra-
cortical processes are being sustained in full vital activity, there is

486 Mary Putnam Jacobi

no room left for the monotonous repetition of an isolated process
which has been excited by a peripheric stimulus. And of all the
processes which may be so excited, those resulting in conscious
sensation are evidently the most easily submerged, for a past sen-
sation is immeasurably more difficult to reproduce than a past
emotion or a past idea.

With a normal brain it is, in fact, absolutely impossible to
reproduce a sensation without repeating the stimulus which
occasioned it.

Abnormally, however, this reproduction or this persistence
occurs under several circumstances.

If the total vitality of the brain be for the moment diminished,
the intracerebral process excited by a peripheric irritation as-
sumes a disproportionate intensity to other intracerebral pro-
cesses. Hence the familiar observation of the generation of per-
sistent pain, neuralgiform or other, in ansemic, exhausted, or
malnourished persons. Or if, from the original constitution
of the brain and character, sensations habitually occupy a dis-
proportionately important position in consciousness, the occur-
rence of a painful sensation tends to persist because the phases
of conscious life which arise in incessant succession, so far from
drowning out and submerging the sensation, are themselves
invaded and absorbed by it. The emotions and ideas become
enlisted on the side of the sensation, amplifying it far beyond its
original scope, and by just as much tending toward its indefinite
perpetuation. This seems to be the sequence of things in con-
stitutional hysterics, to whose consciousness bodily sensations are
always disproportionately important; or further, the circum-
stances accessory to the production of the sensation may at the
outset enlist the other cerebral activities to the amplification of
the sensation. Thus, when there has been such just cause for
fright or shock, as often happens in traumatisms, or even when
the pain has originated in an unfamiliar and therefore possibly
mysterious procedure, such as the plaster-of-Paris apparatus for
fracture, which caused a severe hysterical neurosis in a case re-
lated by Charcot. I have myself seen a similar case.

In cases like the foregoing, the present conscious life of the
brain is permanently dominated by a past experience, morbid,
not in its occurrence, but in its persistence. Admittedly an
immense number of pains and painful affections are to be so

Suggestive Therapeutics 487

explained. And it is precisely such pains which constitute the
best objective for the therapeutic influence of hypnotism.

When this is successful it acts in two ways: By the sleep
wherein is initiated the amnesia characteristic of normal sleep;
and by the suggestion, which focuses upon a narrow point, and
therefore with great intensity, all the cerebral activity of the
present moment. Without the suggestion, the hypnotic amnesia
would be as transient as is the amnesia of normal sleep. But
without this induced amnesia, which increases the suggestibility
of the patient in a manner confessedly most mysterious, the sug-
gestion would not obtain a sufficient foothold in the mind — i.e.,
would not be recorded with sufficient depth in the brain.

The occasional successes of the faith curists, however, who
operate by suggestion unaided by the sleep, show that the former
alone is indispensable. The same proof is offered by more
ordinary forms of suggestion. Evidently the imposed suggestion
acts along the same lines as do the normal cerebral activities in the
cases where a sensation promptly ceases with the cessation of its
cause. The mind is made to think of something else. It is a
familiar fact that under sufficiently intense mental preoccupation,
severe irritation may fail to awaken sensations even at the mo-
ment of their maximum operation: thus wounds may be unfelt
during the excitement of battle. Into the intense activity of the
stmi total of the brain processes the isolated process at the basis
of the sensation is unable to introdue. If this paradoxical in-
ability be possible for a present sensation, or, more correctly, for a
sensory process whose cause is at the moment operative, it is more
easily conceivable for the central brain process which is only
reviving a past sensation. The reason that we ever forget any-
thing is because, so long as the brain is alive, it is compelled at
every moment to be occupied with something new. The neces-
sity may be at least metaphorically compared to that by which
medicBval writers were compelled to efface the writings already
inscribed on parchments in order to utilize these for new
inscriptions.

It does not seem as if chronic disease, certainly not chronic
pain, had ever been included within the original scheme of
Nature. Sudden injuries from external agents are evidently
anticipated. These are to be as promptly arrested, resisted, and
rejected. The wound may be fatal because overwhelming; but

488 Mary Putnam Jacobi

if less than fatal, it is expected to heal, and be forgotten as com-
pletely as a landslide on a mountain which has become overgrown
with grass and trees. Modern hfe has become enormously en-
larged by the modern strengthening and amplification of memory.
Perhaps the vast enjoyments to the race of the historical memory
of past ages, rescued by it from obHvion, are purchased in part at
the expense of an inconvenient increase in the tenacity of the
personal memory, and especially of personal organic memories,
where forgetfulness is so often more desirable. The persistence
of a disturbing past sensation tends to inhibit other cerebral
activities, exactly as these, when fully developed, tend to sub-
merge it. Hence, the well-known tendency to the constant
increase in the range of morbid phenomena under the depressing
influence of a single pain, either mental or physical.

It is cases of neurasthenia which have developed in conse-
quence of such insistent insults to the brain that should be justi-
fiable to hypnotism; while neurasthenia due to malnutrition,
and with no primary cortical disturbance, rests on an entirely
different basis, and demands different handling.

An extremely interesting circumstance about the post-
hypnotic suggestion is, that it seems to encounter a definite,
almost a measurable, amount of resistance, and this can only
gradually be overcome. During the hypnotic sleep it is often
possible to impose the wildest ideas upon the patient's acceptance
those most contradictory to all his past experience. But the
post-hypnotic suggestion directed against his past and deeply
rooted experience of pain can not proceed so abruptly. In many
cases (I do not say in all) it appears that if the patient be assured
that on awakening he will be entirely relieved of his pain, the
suggestion will fail. If, on the other hand, he be told that his
pain will be diminished, this holds true; and in successive sea?ices,
by successive diminutions, the vanishing point will be reached, or,
to judge from some of the recorded cases, the assurance of com-
plete relief will be followed by partial relief, and the apparent
failure of the prophecy does not seem to occasion enough skepti-
cism to prevent successive suggestions from accomplishing the
purpose. These facts of resistance, gradually overcome, and
which seem sufficiently well attested, point to the physical basis
of the entire mental experience. In some mysterious way,
whether dynamically or otherwise, it is unnecessary to speculate,

Suggestive Therapeutics 489

a material record has been effected in the tissue of the brain,
and this can only be changed through newly induced intracere-
bral processes. The facts may be utilized to throw light on the
processes of conviction in regard to other mental phenomena than
sensations. No belief once rooted in the mind is ever changed
suddenly and in toto. If a man is being converted from the belief
in eternal punishment, he first surrenders for ordination, then
infant damnation, and finally, little by little, the whole blessed
doctrine is upheaved, enucleated, and falls away under the
pressure of mental activities occupied with something else.
These grow beneath a fixed idea, intrinsically repellent, like
granulation tissue beneath a foreign body in a wound, and push
it, little by little to the surface.

So with the morbid idea which constitutes pain, when, indeed
pain is a morbid idea. When it is not — i. e., when it is the normal
response to a peripheric irritation — hypnotism can only act by
securing intense mental preoccupation, and the hypnotic sleep
must be prolonged during the occasion. In this way it seems
sometimes to happen that the hypnotizer is able to overcome the
violent suffering of childbirth.

The return of pain on awakening from an hypnotic sleep
implies that the sensation which could not intrude itself upon
consciousness during the intense preoccupation of that sleep is
able to do so when this preoccupation relaxes, and the ordinary
plane of consciousness is resumed. When a verbal suggestion
made during the sleep begins to operate afterward, it is clear that
the idea embodied in the suggestion has been apperceived, and
has begun to modify the sensation. If the physical basis or
aspect of the idea be, as we may provisionally conclude, some
particular "set" of communications between cortical neurones, it
should be expected that this must change with the apperception
of every new idea, or, to put it in another way, the existence
in consciousness of a new idea implies that the "set" of the com-
binations which coincided with the previous idea must have
changed. In trying to persuade a person by ordinary sug-
gestion to cease feeling a pain, because it is irrational to feel a pain
for which there is at the moment no cause, the difficulty lies in the
fact that to the "set" of combinations which begins to be estab-
lished by the apperception of this suggestion is opposed the "set"
which underlies the conscious sensation, so that the former does

490 Mary Putnam Jacobi

not succeed in establishing itself widely enough in the brain.
It must, however, establish itself to a certain extent, or it could
not be apperceived, recognized, at all. The same suggestion
repeated during the amnesia of the hypnotic sleep encounters no
opposition, and is therefore enabled to obtain a certain degree of
foothold. With the disappearance of the amnesia the brain falls
back into its previous "set," and the antihypnotic sensation re-
appears. But when, as happens in the successful cases, the sen-
sation is weakened, this can only mean that other portions of
brain activities have been so aroused as to oppose the extension
of the cortical processes which underlie the sensation. The sen-
sation had hitherto existed unchecked, because believed without
question. This means that it had seemed perfectly congruous
with all the mental phenomena existing at any present moment.
And this again, on the postulate that to each mental phenomenon
if to any, corresponds some physical process in the brain tissue,
must mean that the physical process in the ideo-sensory centre of
the cortex did not interfere with the cortical processes otherwise
or elsewhere going on, however much it had interfered with, had
inhibited, processes which should go on, but which had ceased
and had been forgotten from consciousness. The implanted
suggestion that at a given present moment the pain did not exist,
however really it might have existed in the past, shakes the
hitherto unquestioning belief in the externalization of the
sensory processes in the cortex ; it tends to break up an hallucin-
ation to whose support the total brain activities had hitherto
unwittingly conspired, and when the physical process to which the
suggestion corresponds, the physical "set" of the brain tissue
has been repeated often enough — the obstinate "set" engendered
by a past and uncontradicted experience gives awa3^ "Be-
cause I suffered once is no reason that I suffer now; as no new
reason has arisen, it must be that I do not suffer. In fact, I
do not suffer." These seem to be the successive phases of con-
sciousness traversed by the subject of a successful post-hypnotic
suggestion.

The so-called "subliminal consciousness" is the totality of the
past experience, including much ancestral experience. Since,
under various influences, elements of this can be revived from the
static records in the brain and called up into consciousness — i. e.,
called from the past into the present — this may be named the

Suggestive Therapeutics 491

potential self as distinguished from the actual self. In combating
an isolated mental phenomenon, as a centrally originated pain,
the suggestion appeals to this mass of intricately recorded experi-
ence. It must be congruous with this, for if incongruous, it will
be influential only so long as the hypnotic sleep lasts, and can
have no after-effect. All the previous "sets" of the brain during
which no pain has been felt may be revived to establish the pre-
dominant habit by whose predominance the isolated experience
of pain is gradually crowded out.

If the totality of organic experiences did not so preponderate,
the post-hypnotic suggestion would be ineffectual, because it
would have no support, no "purchase" in fact. Indeed, it is
ineffectual where the elements of the brain cortex are organically
diseased, as in insanity, imbecility, or idiocy; where their func-
tional combinations or "sets" are presumably feeble, as in
severe hysteria, and in neurasthenia with certain grades of mental
feebleness ; in the grand neuroses, where ideo-motor or ideo-sen-
sory centres are not primarily involved, as in epilepsy and
hysteria major.

It is also ineffectual where the logic of the situation is strongly
opposed to the anodyne suggestion, and affirms not only that
pain is felt, but that it ought to be felt; as in most cases of oper-
ative procedure. Post-hypnotic suggestion seems to have no
effect upon labor pain, yet it has proved possible in a certain
number of cases to maintain an hypnotic sleep, with attendant
analgesia throughout the labor. Here, however, it is necessary to
maintain a constant reiteration of suggestion after pain ; the class
of cases characteristically suited to hypnotic therapeutics are
those of functional or habit disability. These embrace pho-
bias in the performance of certain voluntary and coordinate
and complex actions of tremors and other muscular disabili-
ties, the habitual incompetence of certain unstriped mus-
cular organs — as the vesical sphincter in incontinence of urine,
and the muscular coat of the intestine in habitual constipa-
tion, the recurrent irritability of other visceral muscles, as of
the stomach in incoercible vomiting. The underlying principle
in all these cases is evidently the same. The failure to perform
a given act having been recorded in the brain, is remembered,
and being remembered by an organism whose present vitality is
insufficient, tends to repeat itself, the tendency increasing with

492 Mary Putnam Jacobi

every repetition. The tendency lies in the brain, not in the
somatic tissues themselves, and the aim of the hypnotic sugges-
tion must be to dislodge the deeply recorded memory of failure
and to oppose to it a mental conception of success. The sug-
gestion at first can present this conception as an idea ; but, fre-
quently enough repeated, this idea, like all others sufficiently
impressive, becomes the personal experience of the person receiv-
ing it. As a present experience it is naturally more powerful
than the memory of past failure. But as that memory has
attained an unnatural predominance, it is necessary to tempo-
rarily obliterate it by the device of the hypnotic sleep during the
time that the suggestion is being made to the mind, and is also
being recorded in the brain. As in regard to the effect of post-
hypnotic suggestions upon pain, the definite degree of resistance
which is discovered to the suggestion as soon as the amnesia dis-
appears (and this, although at the time the suggestion was made
and apperceived neither consciousness nor evidence of resistance
was present) proves that the suggestion acts through the in-
direction of a definite cerebral process, which ultimately counter-
acts another cerebral process already established. Functional
disabilities, however, indicate clearly what is only hinted at in the
case of morbid pain — namely, that cerebral activities are involved
much in excess of those ascribable to any one sensori-motor centre.
Emotions of fear, shame, despair, judgments of impossibility
and inconceivability, are evidently all present — in other words, a
large area of conscious life is invaded, or even, during the mo-
ments that the disability is made manifest, the entire area of con-
sciousness. Hence the peculiar anguish which often attends
these states. Yet this may be all resolvable into the single fact
that the first experience of functional failure was not forgotten,
but morbidly remembered, and that no contrary experience has
yet been registered in the brain or consciousness. There seem
to be more ways of getting round this form of morbid memory by
simple, non-hypnotic suggestion than in the case of pain, and for
the reason that the pain is constant, the disability intermittent
and variable in degree, so that within the sphere of the voluntary
muscles it is possible to build up experience of success by means of
finely graduated effort, starting from any given minimum. This
can not so readily be done in regard to the visceral disabilities, as
vomiting, constipation, incontinence of urine, although in regard

Suggestive Therapeutics 493

to the two first many indirect devices are familiar to physicians,
and often employed.

The "auto-suggestion" to which authorities on hypnotism so
often refer, and which is said to offer serious obstacles to hypnotic
suggestion, can only be a certain "set" of the brain processes, or
neurone combinations, effected by the record of previous experi-
ences. It is difficult to see how any will process can have anything
to do with the matter. Indeed, I fail to understand how the will
intervenes either in the theory of hypnotism or in modifying the
course of its phenomena. Perhaps one of the greatest indirect
utilities which is to result from the study of hypnotism may be
the abolition of the fantastic attempt to urge the control of
nervous phenomena of central origin by an energetic effort of the
will. To the extent to which such phenomena depend upon cen-
tral impressions they may be combated by other impressions,
spontaneously or artificially generated. But such impressions
can not voluntarily or willfully be produced.

From the moment the organism has deviated from its normal
state of forgetting the past in the incessant creation of the present
which alone constitutes its sphere of consciousness, it has become
dependent upon external aid for restoration. Happy he for
whom such aid can be adequately secured!

The demonstration that the communication between the
nerve elements or neurones of the nerve centres was effected by
contact and not through continuity of structure, promptly and
almost irresistibly suggested the hypothesis that this contact
could be interrupted. Further, that through multiple rearrange-
ments and combinations of contacts, and their interruptions,
many physiological and pathological phenomena could be ex-
plained— thus sleep, hysterical restrictions of consciousness, etc.
The doctrine has already been formulated by Lepine, who seems
to have been the first to do so;^ by Duval, ^ by Dercum,^ who
extends the theory to the explanation of hypnotic phenomena.
I have not ventured to be so precise, but to use a more general
formula which would remain applicable whether the new and
fascinating theory of movable neurones be substantiated or not.

' Un cas dliysterie. Revue de med., 1894, p. 727.
* Theorie histol. du sommeil. Soc. biol., 1895, p. 74.
i American Journal of the Medical Sciences, 1896, cxii, 151. Ram6n y
Cajal admits passive movements by interposition of neuroglia cells.

ADDRESS BEFORE THE WOMENS MEDICAL ASSO-
CIATION ABOUT 1900.

[First Page Lost.]

The disadvantage of individual feebleness is only to be
palliated by means of the union of forces, and we must certainly
know ourselves individually feeble enough to desire to unite.
Unfortunately, it often happens with weaker parties that they
intensify their own weakness by internal discords at the very
moment that the closest union, the most frank and fraternal
friendship, can alone save their cause and win the day. "Yes,"
said Benjamin Franklin, on a famous occasion, "we must all hang
together or without doubt we shall all hang separately."

The imperfect cohesiveness, so apt to be observed among
women, their imperfect sense of class interests and of the neces-
sity of vigorous enthusiasm for their class, has often been ex-
plained by the traditional isolation of women from one another,
each as the center of a family and called upon therefore to play
her hand alone. Goethe commented on this many years ago, and
considered it a reason that girls should never be dressed in uni-
form. I think, myself, that the lack of political rights and of the
habitual exercise in masses of political duties, is largely responsi-
ble for the deficient ability for collective action which is so notice-
able in women, a defect which is only slightly less marked among
medical women than among others.

Yet we are doubly members of a class, and therefore set apart
to support each other. We are first physicians, and then women
physicians, a lesser circle within a greater, to be governed, how-
ever, by essentially the same principles. The great principle
that in most modern times has revolutionized the position of the
medical profession in society is that its members are expected

494

Address 495

to be constantly engaged in the investigation of truth. The
passive uncritical acceptance of old truths, is not sufficient. All
over the civilized world thousands of eager and laborious minds
are at work night and day to try to roll back the thick curtain of
darkness which still covers so much : to try to wrench some new
fragment of truth from the abysmal unknown. The medical pro-
fession has always existed, but it has not always been respected.
I might say that it was not respected during the many ages when
doctors did nothing but write prescriptions, when their business
was supposed to be to treat disease, but not in the least to know
anything about either disease or life. During the time, in a word,
when the apothecaries who handled drugs and the barbers who
handled knives, were supposed to have nothing in common with
the physicists and philosophers who sought after truth. Now,
do we not as women, somewhat tend to relapse into this status of
antique medicine — to be very anxious to learn how to treat our
cases, but rather indifferent to the vast mass of subtle and curious
problems which modern medical science rolls in upon us? The
practical evil of this indifference is that whatever class of persons
is guilty of it, becomes in the long run incapable of practical suc-
cess, and moreover, loses the reputation through which alone can
come opportunities for practical effort. As I speak, however, I
remember the work of real investigation that has been done by
several of our colleagues: I recall Dr. Williams' researches on
diphtheria; Dr. Wollstein's essay on the bacteriology of infantile
diarrhoea; Dr. Baldwin's recent experiments on urea; the report
on the extraordinary case of foetal icthyosis made at the Ameri-
can Medical Association by Drs. Cordes and Daniel; not to
speak of that older case of Dr. McNutt on diplegia, which seems
to have made the tour of the civilized world. Could we extend
our membership to Baltimore, we could include Claribel Corre,
whose case of brain sarcoma was a most brilliant contribution at
the Philadelphia Alumnae Association two or three years ago;
and Florence Sabin, whose wonderful model of the microscopic
structure of the brain, is a proof equally cogent and welcome
of a solid intellectual capacity among women of a peculiarly rare
order. I refer, without permission, to those among our colleagues
to show, were it necessary, that we have with us the beginnings
of everything which has made the medical profession at large
useful, respected, rich and powerful. But the fact is not as yet

496 Mary Putnam Jacobi

so well recognized by the world that we can afford to let it alone.
The difficulty for women in this as in every other respect, lies, not
in quality but in quantity, or in such defects in quality as result
from defects in quantity. Our writings are apt to be thin,
because they do not contain enough facts, do not go over enough
ground, do not repose upon a rich enough background of liter-
ature. Now the richness of much contemporary medical writing
is only obtained through the cooperative work of several people.
Dr. Barker, of the Johns Hopkins, has just published a treatise on
the nervous system, whose erudition, even in regard to the biblio-
graphy, is amazing when considered as the expression of the
labors of a single man, much of whose time is employed otherwise
than in the preparation of this book. But the professor was able
to call upon colleagues, and pupils and students of the university
to assist him. In Paris, when the candidates for hospital
positions are writing the theses which constitute the most import-
ant competitive test, and which must be handed in, printed,
a fortnight from the time the subject of them is given out, they
summon all their friends to join in this preparation. Not one
man, but a dozen are at work night and day reviewing the notes
which have been previously collected during many years on all
kinds of subjects, and so systematically arranged that they can
be referred to at any moment. I should like to see this associ-
ation organized, for part of its function, as a permanent com-
mittee of the whole for constant research. The first years after
graduating from the medical school are very apt to be mentally
wasted by young physicians who have failed to be caught up
within the inner currents of an intellectual center. They want to
do something but they do not know what to do. They forget
that one employment is permanently open to every intelligent
human being — the employment, namely, of learning something
new, a definite series of new things. The field is so vast, it can
never be exhausted, and the work is always exciting. To set out
to learn something new, new for oneself, even if already known to
the world, is quite a different enterprise from that of getting up an
article for a medical journal, or even for the meetings of a medical
society. The reason that there is apt to be so much difiiculty in
securing papers for meetings and that the efforts to sustain
medical journals by women are apt to be such failures, is that
the cart is put before the horse : the writing has not been preceded

Address 497

by the steady, prolonged work which can alone collect such new
facts or new views as should be worthy of publication. The
article therefore if written, is liable to be merely a rehash of things
which have been said a dozen times before.

I should propose that this association appoint a committee
upon subjects for investigation covering many branches. We
need to have a center for ourselves where some definite work is
always going on, where a series of researches are constantly
being made, and various classes of material being accumulated,
into which any new comer may freely dip. Without pretending
to be exhaustive I would suggest :

First: A series of embryological studies in the chick, in-
definitely renewed, and resulting in numerous microscopic
preparations to be accumulated in a museum for frequent refer-
ence. These series could be frequently interrupted by prepara-
tions from other animals, including the human, whenever a fortu-
nate chance rendered these latter accessible.
Second : A series of studies in bacteriology.
Third : A similar series in haematology where the one item of
the malarial parasite has just offered a multitude of new details
for investigation.

Fourth: Continuous work in the preparation of a nervous
tissue, both for normal and pathological anatomy. The great
variety of new methods recently devised, and applicable to the
tissues of freshly killed healthy animals afford endless food for
thought and scope for practise, and the time required to prepare
tissues for staining and section is so long, that the individual
observer unless entirely devoted to this kind of work, is easily
discouraged from undertaking it.

Fifth : I am not sure that it would be well at present to pro-
pose analogous physiological work involving vivisection. But
there is a new and large field of clinical physiology, embracing
experiments on human beings with various instruments of
precision such as the plethysmograph, or instruments for graphic
curves, and which require such a large number of observations
as can only be fruitfully made by groups of observers working in
concert. Experiments in psychophysics, for which Scripture's
manual offers a reliable guide, would fall under this head.

Sixth: Records of groups of clinical facts in medicine and
surgery, collected from the experience of the association, from the

498 Mary Putnam Jacobi

books of hospitals and dispensaries, to which access had been
obtained; reenforced by bibliographical research, the whole
analyzed and summarized and kept, so to speak, on top, ready for
use. I think this could be made one of the most popular of our
departments. It seems to me that upon application, this associ-
ation could secure the use of the laboratories in the old medical
college. Upon what terms, I have not yet imagined. That
would remain to be considered. But it was said in a general way,
that these rooms should stand for the use of young physicians
"wishing to do post-graduate work," and the plan I suggest
is more voluminous and solid than that. It implies the creation
of an intellectual atmosphere to be permanently breathed by all
of us, for our constant and needed invigoration. It is only those
who are constantly breathing such an atmosphere who can hope
to progress in medicine, and to resist the tug of the mass of dead-
ening influences which are constantly tending to drag them down
into pettinesses and in the press of daily routine and anxieties, it is
difficult for any isolated individual, especially if she be a woman,
to break away and start afresh some new enterprise, which more-
over she would be obliged to carry on alone by her unassisted
strength. Much easier if the habit were once established as a
matter of course to add daily to the other business of the day,
some share in work already established and going on. To do this
as the bees work, without any especial reference to individual
advancement, but the intention of contributing to the upbuilding
of the hive.

The evenings of our monthly meetings would upon this plan,
be in part always devoted to some report from some stage of the
continuous work. Room would be left, however, for any in-
dividual effort that should occur, but which would then have a
permanent background of solid work with which to be con-
trasted and compared, and not as now is too frequently the case,
have only a background of nothingness, and be obtained by means
of laborous solicitation and conceded as a personal favor.

The meetings of the Hospital Section would on the other hand,
be devoted entirely to personal experiences, as distinguished
from systematic exposition of a given subject. These meetings
should be like a day book as compared with a ledger.

There is a second great class of interests which our association
is bound to consider, and which differs radically from the scien-

I

Address 499

tific subjects we have been so far speaking about. In the pursuit
of truth, and while engaging in work that may hope to demon-
strate something new, we are able to think of ourselves simply
as human beings. But when we consider our practical daily
work in the treatment of the sick we very soon find that we are at
a considerable disadvantage as compared with many other
human beings. So long as the public hospitals are not open to
women, women remain deprived of the fundamental indispen-
sable basis of their entire work. I am often surprised that this
unjust privation does not seem to excite among women in general
the same vehement indignation which I feel about it myself.
Here is where vigorous collective action would seem to be espe-
cially necessary. There are two kinds of hospitals to be con-
sidered, the large and the small. To the large hospitals, as nota-
bly the Woman's Hospital, admission must be sought by means
of increasing pressure of public opinion. But to the small hospi-
tals, which are poor and struggling and always in debt, there are
frequently opportunities to obtain admission by the quid pro quo
of purchase. It is indeed comical, in view of the lofty objections
so commonly urged against the presence of women, to note how
rapidly these melt down under the influence of a few thousand
dollars. Two hundred thousand dollars purchased for women
the permanent entrance to Cornell University; $100,000 threw
open to them the inestimable advantages of the Johns Hopkins
Medical School. I have a small hospital in view, where I believe
that a donation of $10,000 would radically change the entire
mental horizon, and permit what has hitherto been refused, the
admission of women both to the staff of internes and also perman-
ently to the visiting board. I do not want to speak in too much
detail of this hospital on this occasion, for it would be deleterious
to the success of the plan should it be known or talked about
publicly in advance. But my plan is to try to persuade ten
persons of whom I have several in mind, to contribute $1,000
a piece, or rather to make a promise of such contribution on condi-
tion that the hospital agree to always have one woman among its
internes, admitted like the others after competitive examination,
and also one woman on its board of visiting physicians. I think
this association might pledge itself to obtain the promise of a
thousand dollars of this donation, promise only to be redeemed
in case the rest is raised. Should one hospital be secured for this

500 Mary Putnam Jacobi

plan an immense step would have been gained, the beginning of
an immense advance.

Many and contradictory are the reasons alleged to oppose the
admission of women to the hospitals. But they all sift down to
one; namely, the belief that it would be impossible to make a
junior interne who was a young man, submit to the official superi-
ority of a young woman who should have become senior. There
is a dogged prejudice on this point, which must be overcome, and
as there are no resources on hand to overcome it by force, it must,
as on other analogous occasions, be bought off.

In disbanding the Association for the Advancement of the
Medical Education of Women, I left it to be understood that the
New York Medical Association of Women would undoubtedly
appeal for assistance to the same friends who for so many years
had been helping them in the old times. Our methods of appeal
must now be different. Thirty years ago there were few gradu-
ated physicians and the undergraduates were on the curiously
childish basis. The effect of the childish estimate in which they
were generally held by their patrons was often perceptible in the
managment of the infirmary and dispensary today, and since the
organization of our present association, the women physicians
of New York should claim to stand on their own feet, to work for
their own interests, in the same resolute way in which, for in-
stance, groups of foreign physicians have developed themselves
into powerful organizations. The methods are always the same,
definite aims, enthusiasm about these, willingness to make per-
sonal sacrifices to advance them, further willingness to advocate
these among wide circles of friends, and endeavor to secure their
support. And for the moment the two schemes I commend to
your exertions are : first, the organization of a system for perman-
ent research; and, second, the collection of $10,000 as a donation
to a certain small hospital, to be given on the condition of admit-
ting women physicians as internes and also permanently on the
medical board.

DESCRIPTION OF THE EARLY SYMPTOMS OF THE
MENINGEAL TUMOR COMPRESSING THE CERE-
BELLUM, FROM WHICH THE AUTHOR DIED.
WRITTEN BY HERSELF.

... I DO not believe that any one ever had such good health,
certainly not any better than I enjoyed until the age of 54 years.
During this period, I sustained many trials, some of a nature
peculiarly calculated to break down the nervous system of
women, but I did not break down. Indeed I often reflected with
pleasure that not only my muscles, digestive apparatus, etc., were
always in perfect running order, but my brain was always singu-
larly clear and buoyant. It seemed to me often as if I lived in
a glass house on the summit of a lofty mountain where I could
see in every direction an almost illimitable distance looking
through an atmosphere of blue and gold. The delight I experi-
enced in the clearness of this view was immense. On account
of it I was never conscious of depression or of irritation for more
than a few moments at a time. I lived in an equable golden calm
as in a sunrise or sunset cloud. I emphasize this habitual con-
dition because it was on account of it that the first symptoms
of the present illness became so conspicuous from contrast and
attracted my attention, as otherwise they might not have
done.

In the winter of 1896, ... on waking one morning I experi-
enced a very sharp pain running transversely just below the occi-
put. It lasted between three and five minutes, then disappeared,
and was heard no more of throughout the day. But the next
morning at precisely the same time the suboccipital pain returned
with precisely the same characters, and lasting precisely the same
length of time. From this date, the same thing happened every

501

502 Mary Putnam Jacobi

morning for four years, and the pain never occurred at any other
time of the day. But in 1900 it did begin to come on occasionally
at other times, always, however, lasting such a short time, three
to five minutes, that it did not seem to me deserving of much
attention, however severe it was while it lasted. Finally, in the
year 1900, the morning pain instead of disappearing persisted
and increased in severity, in extent, and territory, became compli-
cated with nausea, then vomiting — assumed in fact all the charac-
ters of an ordinary sick headache.

I think I had never had a sick headache before. It lasted
from early morning until early in the afternoon, then died away
under the influence of phenalgine. This sick headache recurred
every six months during the next year and a half. In the inter-
val the head was as clear as usual, only the sharp attack of sub-
occipital pain continued to occur for five minutes every morning.

In June of 1901, I joined a party in an expedition to the
Yellowstone Park, where I spent a week. On the first day, and
after the thirty-six hours' railroad ride, I had a sick headache
with moderate pain, but much nausea. The next day, and for
a week, I was perfectly well. But the day before leaving I in-
dulged in a hot bath from the geyser water and was seized in
the night with an extremely violent pain in the head, not limited
as usual to its posterior third, but extending all over, and soon
accompanied by retching and vomiting. These symptoms were
so severe in the morning that I was quite unable to rise and ac-
company the party home. I remained in bed all day, took phenal-
gine, and gradually recovered. The following winter, however,
I noted a gradual increase in the head symptoms occurring on
waking in the morning, also a great difficulty in arising from a
recimibent to a sitting position. Frequently there was an attack
of nausea, and even vomiting, after getting out of bed. Great
irritability of the bladder at this time, and that also frequently
continued during the day, but altogether the first few hours in
the morning were always pretty miserable. Nevertheless, I man-
aged to do my work, usually after 10 a.m., and felt pretty well,
but during the winter of 1 901 -1902, the attacks of sickness be-
came more frequent, and towards spring about once every two
or three weeks I was laid up in bed all day. At the end of May,
I had an especially severe attack, which was arrested this time
by nitroglycerine. I was then ordered to bed for a fortnight, the

Early Symptoms of Meningeal Tumor 503

first such experience in my life, during which time I felt quite
ill. I continued to take a few tablets of nitroglycerine
daily.

On the seventh of June, I went into the country with my
family, and stayed there until the seventh of October. Three
daj's before I went to bed I suddenly lost in great measure my
power of walking. I was walking home, . . . when it suddenly
seemed to have become almost impossible to drag one foot after
another. It was with great difficuly that I climbed up the steps
to the house. This was the first of June, and from that date to
the present my walking power has been greatly reduced. During
the summer I at first only attempted to walk a few steps off the
piazza. After a month I could sometimes walk a quarter of a
mile, and in three months I could occasionally walk half a mile.
There was no pain or stiffness in the legs at the time, but since
the last week I have noticed, with some concern, that a great feel-
ing of heaviness and dragging is liable to come on in the end of
the back, and especially after walking. I cannot now walk more
than from three to six blocks. At the time of this limitation in
extent of walking capacity, I began to totter somewhat in walk-
ing. On going downstairs there was a tendency to pitch for-
wards. This tottering has not increased, but it has persisted.
Since the last two months, I cannot walk more than three or four
blocks, and that with the aid of a cane and an assistant's arm.
From time to time I have fallen suddenly — not when out of doors,
most frequently upon arising after sitting for a long time, per-
haps especially in the evening. I would fall to the floor, and
experience considerable difficulty in getting upon a chair. The
fall was unaccompanied by either vertigo, giddiness or pain.
Indeed no different sensation in any part of the body: the legs
simply gave way as if I had been on skates. After a moment or
two, I could climb to my feet again and felt none the worse for
the adventure. These attacks of falling have occurred about
once in three or four weeks during the winter.

I do not find any symptoms of paralysis in any of the four
limbs, either of motility or sensibility. Neither are there cramps,
contracture of muscles, or stiffness in them. I can climb in and
out of a bath tub usually with ease, though occasionally I need
the maid to assist me, as also in arising from the bed in the morn-
ing. There is no steadiness or regular progression in this nor

504 Mary Putnam Jacobi

in any of the other symptoms. There is a constant sense of gen-
eral fatigue and inability for exertion.

A slight tremor has occurred in my right hand during the last
winter. It comes during repose and is scarcely rhythmical; its
excursion is very small; it is not developed during motion or
exertion. During the last two or three weeks, I think this tremor
has been much less, and often for many hours it would be en-
tirely absent. There is no fibrillary tremor.

A change in mental condition began in a subtle manner about
six years ago. I began to lose the initiative, which had formerly
been so active with me. I was not at all depressed or melan-
choly, but became relatively indifferent. It seemed as if a fine
gauze veil were thrown over all the objects in which I had for-
merly been so intensely interested. It was like the life after
death as the Greeks understood it when they described Hades.
My interest in contemplation persisted, and even increased, but
I acquired an increasing reluctance to effort and voluntary men-
tal exertion. I appreciated Schopenhauer's "Condemnation of
the Will," and felt confirmed in my view that his entire theory
sprang from a deep inner consciousness of personal weakness of
volition. This impressed me the more from its sharp contrast
with the vivacity and strength of volition which had been a lead-
ing characteristic with me all my life. There was a facility of
fatigue after mental exertion, quite comparable to that after walk-
ing. This became marked at the same time with the latter, that
is after June, 1903, although the sense of loss of initiative had
begun, as I have said, six years before. In the last week I have
had for the first time a dragging heaviness in my left arm, and
some stiffness when I move it backward.

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INDEX

Abdominal typhus, 466

Abscess, psoas-iliac, 87-8; of the
liver, 102-4; traumatic, 104-6

Academy of Medicine, Belgian, 28

Academy of Medicine, Paris, elec-
tions at, i; reports and memoirs,
I S.

Acclimation, 37

Acne, 126

Air, the, and putrefaction, 173-4,
176, 197, 199

Albiuninuria, letters on, 143 flf. ;
in Bright's disease, 144; five
periods of the history of the doc-
trines concerning, 144-6; 161,
162, 163; scarlatinous, 163; 164,
166, 168

Alexandria (Egypt), Medico-Surg-
ical Society of, 102

Ameloid degeneration of the kid-
ney, 148, 149, 155, 156

American Journal of the Medical
Sciences, paper reproduced from,
299

American Journal of Obstetrics and
Diseases of Women and Children,
papers reproduced from, 240, 311

"American method" in treatment of
vesico-vaginal fistula, 14-15

Ammonia, muriate of, in treatment
of catarrhal fevers, 5

Anaemia, pernicious, 322-3

Anaemic kidney, 147, 148

Anaesthesia, origin of modern, 19-
20; extent of, produced by atro-
pine, 214-17

Anatomical specimens, new method
of preserving, 47-8

Ankylosis in gonorrhoeal rheuma-
tism, 134-5

Antisepsis, 171 ff.

Aphasia, M. Broca's theory of, 2;
a case of, with autopsy, 2-3; me-
moir of Dr. Fabre on, 73-5

Archives of Medicine, papers repro-
duced from, 326, 357, 391

Aromatics, 284

Arsenic in cerebral congestions,

52-3

Arteries, eflfect of atropme on ten-
sion of, 209 flf.

Arthritic herpes, 124

Arthritis, see Rheumatism

Asphyxia of the new-born, 405

Association for the Advancement of
the Medical Education of Women,
500

Atelectasis, foetal, 406

Atrophy, acute fatty, of new-born,
407; of muscles of trunk and
limbs, 58-9

Atropia, eflFect of, in intracranial
pressure, 306-7

Atropine, 205 ff. ; effect of, on heart
action, 206-14; anaesthetic prop-
erties of, 214-17; mechanism of
the mydriasis determined by, 217-
22; effect of, on submaxillary
gland, 221-2; therapeutical appli-
cations of, 222 ff.

Auscultation, discovery of principles
of, by Laennec, 361

Auto-suggestion, 493

B

Bacteria, presence of, in animal pu-
trefying substances, 173-4; "i
water, 174; experimental work
with, 175-6

Baker-Brown, practice of ovariotomy
by, 5

Balsams, 284

Belgium, Academy of Medicine of, 28

513

514

Index

Belladonna, antagonism between,
and opium, and use of, in cases of
poisoning by opium and its deriva-
tives, 223 R.; use of laudanum in
cases of poisoning by, 227-8;
summary of conclusions on treat-
ment of opium poisoning with,
236-9; effect of, on intracranial
pressure, 306

Bezold, experiments on effects of
atropine by, 206, 210-11

Biology, practical study of, 458-62

Bleeding, in typhoid fever, 1 1

Blood in the urine, 161, 162, 163,
164, 166

Blood-vessels, eflfect of atropine on
tension of, 209

Boston Medical and Surgical Jour-
nal, papers reproduced from, 403,

458,478
Brain, location of powers of speech

and writing in, 3 ; sphygmographic

experiments on, 299-310
Brandy, effect of, on intracranial

pressure, 305
Bright, discovery of, in connection

with renal lesions, 143-4 ff.
Bright 's disease, 144 ff., 159. 160 ff.
Broca, M., theory of aphasia, 2
Broncho-pneumonia, 428, 430, 431
Brown-Sequard, 217, 222, 242
Brussels, regulation of prostitution

in, 46
Buhl's desquamative pneumonia, 421
Buhl's disease, 407

Calculus, union by first intention
after lithotomy for, 31-3

Cancer, of the uterus, iodoform in
treatment of, 7-8; of the kidney,
17-18

Cancerous stricture of the rectum,
diagnosis of, 91-2

Cancroid, uterine, 85

Carbolic acid, use of, for dressing
wounds, 1 7 1-3, 198, 199

Carbon, sulphide of, as a local anaes-
thetic, 1 13-14

Casts in the urine, 161-2, 164, 165,
T66

Catarrhal fevers, muriate of am-
monia in treatment of, 5

Catarrhal infections, 285

Catarrhal pneumonia, 428, 431

Caustics, lessened chances of infec-
tion in wounds made by, 178

Cerebral concussion, memoir of M.
Langier on (1867), 1-2

Cerebral congestion, use of arsenic

in, 52-3
Cerebral softening, the characters of,

53-5
Cerebro-spinal nerve-centres, rela-
tions to temperature of the body,

473-4

Charcot, M., 19, 245

Chicago Medical Journal and Exam-
iner, paper reproduced from, 334

Childbirth, difficulties to, in abnormal
narrowness of the pelvis, 109-10

Children, appropriateness of cur-
ing eruptive affections of, 132-3

Children, diseases of, 403 ff. ; de-
velopment of the child, 403-5;
liability of each period to some
special morbid conditions, 405-9;
influence of conditions of foetal and
embryonic life, 409-10; cleavage,
410-11; malformations, 410-412;
curvature, 412-13; effects of ex-
ternal pressure, 412-15; inequal-
ity in rate of embryonic growth of
different parts, 415-16; mutual
limitation of parts, 417-18

Children's Hospital, Paris, 10

Chirone, theory of, regarding action
of quinine in pneumonia, 432-3

Cholera, contagion of, 22-6

Chorea, associations of, with rheu-
matism, 137-43

Cleavage, 410-11

Cleft palate, 411

Clinical study, Professor Tommasi
on, 49

Coffee, effect of, on intracranial
pressure, 308-9

Cohnheim's experiments with ni-
trate of silver, 288-9

Congenital malformations, morbid
conditions associated with, time
limit of, 405

Consumption, see Pulmonary con-
sumption

Contractibility of muscular fibre,
18-19

Convulsions of childhood, 409

Convulsions, tetaniform, 406

Counter-irritation in joint diseases,
362

Coxalgia, treatment of, 106-9

Cranial sutures, ossification of, in
epilepsy, 50

Cretins, 29

Criminals, experiments upon, within
a few moments after execution,

57-8
Croupous pneumonia, 428, 431
Curvature of spine, 59-60

Index

515

Cutaneous eruptions, classification
of, 115; discussion of, 115 ff. ;
pathology, diagnosis, and treat-
ment of, 124 flf.

Cyst, ovarian, 93-7; of liver, hydatid,
case of, 97-99

Cysts, confusion of ovarian and
renal, 15-17; use of drainage tubes
for evacuation of, 97-101

Dartre, 124

Dermatologists of the H6pital St.

Louis, theories of , 114-24
Dermatology, modern, 362
Dextrine in varicose eczema, 114
Dissection, necessity of, 461
Drainage in treatment of empyema,

85-7
Drainage tubes, benefits of use of,

for evacuation of cysts, 97-101
Dropsy, in Bright's disease, 143,

144, 158, 164, 166, 168
Dyspepsia and its treatment, 50-2
Dyspnoea, febrile hysteric, 473

B

Eczema, dextrine in varicose, 1 14
Education, medical, 201-3, 204-5
Emboli, pulmonary, 76-7
Empyema and its treatment by

perpetual drainage, 85-7
Endopericarditis, 137, 140
Epilepsy, depending on premature

ossification of the cranial sutures,

50
Epithelial and gland cells, action of

nitrate of silver on, 284-98
Epithelium in the turine, 161, 163, 166
Equilibrium, loss of, lesions causing,

331-3

Erosions of urinary passages, dan-
gers of, 90-1

Eruptions, cutaneous, 1 1 5 ff.

Eruptive affections of children, ap-
propriateness of curing, 132-3

Erysipelas, iodine in treatment of,
96

Erythema, papular, 126

Erythema nodosvun, 126

Europe, laws of mortality in, 37

Experiments on the living subject,
necessity of, 459-60

External malleolus, fracture of, 90

Eye, new apparatus for irrigation of,
34; dilatation of iris by atropine,
217-22

F

Facial and palatine paralysis and
loss of equilibrium, caused by a fall
upon the head, a case of, 329-33
Faith curists, 487

Faradaic current as means of diag-
nosis in infantile paralysis, 256-8
Fat globules in the urine, 167, 168
Fatty degeneration of the new-born,

acute, 311-25, 407
Female invalidism, modern, 478-82
Fever, new and old views about,

467; general theory of, 476
Fibula, fracture of, 90
Fistula, vesico-vaginal, 14-15
Foetal and embryonic life, influence

of conditions of, 409 ff.
Fork, swallowing of, perforation of
stomach, and escape through ab-
dominal walls, 104-6
Fracture, of jaw, danger of apparatus
in some cases of, 89; of radius,
treatment of, 89-90 ; of external
malleolus, 90; of fibula, 90; of limbs
of the new-born, 406

Galen, 202

Gastro-intestinal diseases in infants,

408
Genius, ranked among the neuroses

by Moreau, 8-9
Gland and epithelial cells, action of

nitrate of silver on, 284-98
Gonorrhoeal rheumatism, 133-7
Graefe, 35

Granulated kidney, 154
Granulations of Bright, 152, 153,

154 .

"Growing pains," 143

Guerin's system of pneumatic oc-
clusion, lOI

Gunshot and shell wounds, 177-8

H

Hare lip, 411

Harley, Dr. John, 97 ff. ; observa-
tions on effects of atropine by,
206, 208; use of belladonna in
cases of poisoning by opium and
its derivatives, summary of cases
tabulated and commented on by,
231 ff.

Harvard University, curriculum of
Medical Department, 202-3

Heart, effect of atropine on action
of, 206-14, 222; action of quinine

5i6

Index

Heart — Continued

on, 433 flf. ; action of toad venom
on, 433; movements of, 438

Helmholtz, invention of ophthalmo-
scope by, 361

Hemorrhage, spinal, 269-74; umbili-
cal, 313, 317-20, 407; arachnoid,
405, 406; meningeal, 406

Hemorrhages, multiple, 319

Hernia, diaphragmatic, 405

Herpes cincinatus, 125

Herpes Uibialis, 124

Herpes of children, 124

Herpes tonsurans, 125, 127

Herpes zoster, 125

Herpetic zona, 125

Hippocrates, 202

Hoggan, Dr. Frances, 400

Hdpital Lourcine, Paris, 12, 13

Hdpital St. Antoine, Paris, 2

Hdpital St. Eugenie, Paris, 10

Hdpital St. Louis, Paris, theories of
the dermatologists of, 114-24;
therapeutics of, 130-2

Hospital St. Joseph, Lisbon, 43-4

Hospitals, Parisian, appointment of
physicians to, i

Huxley, on qualification of women
for medical work, 379

Hydatid cyst of liver, case of, 97-

99

Hyperaemia of the kidney, 157-8
Hypertrophy of the kidney, 152
Hypnotism, see Suggestive thera-
peutics
Hypochondriacs, nux vomica in the

dyspepsia of, 113
Hysterical fever, 463 ff. ; a case and
its treatment, 463-6; discussion
of "nervous fever" and simulated
diseases, 466 ff. ; importance of
diagnosis in supposed hysterical
affections, 477
"Hysterical peritonitis," 467

Icterus of new-born, 407
Imperial Society of Medicine, 22, 73
Imperial Society of Surgeons, 1 1
Impetigo, 127

Independent Practitioner, paper re-
produced from, 329
India, desire for women physicians

in. 374-5 n-
Indurations, syphilitic, 61-2
Infantile paralysis, pathogeny of,
240 ff. ; study of location of lesion
of, 242-53; modes of invasion of,
in children, 253-5; reactions to

faradaic current as means of diag-
nosis, 256-8; three principal vari-
eties of, 258-9; examination of
muscles at autopsies, 259; in
adults, 259-61; age of patients,
261; discussion of theories of
character of the disease, 261 ff. ;
theory of spinal congestion, 266-9;
spinal hemorrhage, 269-74; affec-
tions of motor cells and nerve
atrophy, 274-80; pathological im-
portance of study of, 280-1

Infantile spinal paralysis, 414

Infants, gastro-intestinal diseases in,
408

Infections, putrid and purulent, 171
ff. ; of wounds, 176 ff. ; catarrhal,
285

Infectious diseases, liability to, in
childhood, 409

Inoculability of tubercle, 65 ff.

Insanity, hereditary, and nervous
diseases, progression of, article
by Dr. Morel on (1867), 8-9

International Medical Congress at
Paris, 1867, 20-2, 34 ff.

Internes, appointment of, in Paris,
81-2

Intracranial pressure, sphygmo-
graphic experiments in study of,
300-10

Iodine in treatment of erysipelas, 96

Iodoform in treatment of cancer of
the uterus, 7-8

Iris, dilatation of, by atropine, 217-
22

Iron, perchloride of, use of, in sur-
gical operations, 42-3

Isolation of surgical wards from
contagious diseases, 45

Jaundice of the new-born, 407

Jaw, fracture of, danger of apparatus
in some cases of, 89

Joint diseases, counter-irritation in,
362

Journal of Nervous and Mental Dis-
eases, papers reproduced from, 446,
463

K

Kidneys, cancer of, 17-18; Dr.
Bright 's discovery in connection
with lesions of, 143-4; alterations
in structure of, 146-58; relations
of lesions of, to one another, 159
ff. ; congestion of, 162 ff. ; fatty
degeneration of, 167 ff.

Index

517

La Charite, Lyons, 26

Laennec, discovery of principles of

auscultation by, 361
Laribaissiere, 12, 17
Larj'ngitis, stridulous, treatment of,

with steam, 10
Laryngoscope, invention of, by

Czermak, 361
Laudanum, use of belladonna in

coimteracting effects of, 226 ff. ;

use of, in cases of poisoning by

belladonna, 227-8
Legrand, Dr. Maximin, 11
Lichen, 126
Lisbon, siirgical results at hospital

St. Joseph, 43-4
Lister, Professor, use of carbolic acid

by, for dressing of wounds, 17 1-2
Lithotomy, imion by first intention

after, 31-3
Liver, case of hydatid cyst of, 97-

99; abscess of, 102-4
Lymphangitis, 179
Lymphatic system and septicaemia,

178-9, 191
Lyons, Imperial Society of Medicine

at, 22

M

MacDowell, Dr. Ephraim, of Ken-
tucky, practice of ovariotomy by, 5

Malformations, 410-iJ

Malleolus, external, fracture of, 90

Malphigian capsule, 151

Malphigian corpuscles, 151, 156, 158

Malphigian plexus, 165, 167

Mammary glands, 29

Marasmus of the new-born, 408

Marseilles, Imperial Society of Medi-
cine at, 73

Massachusetts Medical Society,
paper on study of biology read
before (1889), 458-62

"Medical constitutions," apprecia-
tion of, 10- 1 1

Medical education, 201-3, 204-5

Medical Library and Journal Asso-
ciation of New York, remarks be-
fore, on "Pathogeny of Pyasmia
and Septicaemia," 171-200

Medical Record, papers reproduced
from, I et passim; compliment
paid to, by Gazette Hebdomadaire,
19-20

Medical schools for women, diffi-
culties connected with, 355-6

Medici, Marie de', fotmds La Char-
ity, 64

Medicine, difficulties involved in
study and practice of, 334 ff.;
specialism in, 357-66

Memory a general property of or-
ganic tissue, 483

Meningeal hemorrhage of the new-
born, 406

Meningeal tumor compressing the
cerebellum from which the author
died, description of the early symp-
toms of, written by herself, 501-4

Meningitis, occasioned by other
diseases, 111-13; simulated, 472

Menstruation, 37

Mentagra, 126-7

Mercury, administration of, in syph-
ilis, 11-14

Metrorrhagia, cases of, 83-5

Miasm, influence of, 37

Microzymes, 174, 176, 197

Moreau, Dr., ranks genius among
the neuroses, 8-9

Morphine, use of belladonna to coun-
teract poisoning by, 224 ff.

Motor nerves, paralysis of, by atro-
pine, 214

Mucous membrane, action of nitrate
of silver on, 287

Muscles of trunk and limbs, atrophy
of, 58-9

Muscular fibre, contractibility of, 18-
19; action of atropine upon, 215-
17; action of nitrate of silver on,
288

N

Naso-pharyngeal polypus, operations
for, 62-4

Nephritis, 158, 159 ff.; see also
Bright's disease

Nerve tissue, action of nitrate of sil-
ver on, 287

Nerves, vaso-motor, fimction of, 60

Nervous diseases, progression in, 8

"Nervous fever," conception of, 466

Nervous filaments in nevurilemma of
nerves, 59

Nervous phenomena, curious, 55-7

Neurasthenia, 48S

Neurological Society, paper on prob-
able tumor of the pons read before
(1888), 446-57

New-born, acute fatty degeneration
of, 3 1 1-25 ; diseases of, 405-8

New England, utero-ovarian disease
and reproductive failure in, causes
of, 478-82

5i8

Index

New York County Medical Society,
paper on "Pathogeny of Infantile
Paralysis" read before (1873),
240-83

New York Medical Journal, papers
reproduced from, 419, 483

New York State Medical Society,
remarks upon the action of nitrate
of silver on epithelial and gland
cells before (1874), 284-98

Nitrate of silver, action of, on epi-
thelial and gland cells, 284 ff . ; on
mucous membrane, 287; on nerve
and muscular fibre, 287, 288; ex-
perimental use of, on tissues of
man and animals, 288 ff. ; conclu-
sions from observations made,
296-8

North American Review, paper repro-
duced from, 367

Nux vomica in the dyspepsia of
hypochondriacs, 113

O

Occlusion, pneumatic, loi

Oil globules in the urine, 161, 162

Ophthalmoscope, invention of, by

Helmholtz, 361
Opium poisoning, use of belladonna
in cases of, 223 ff. ; summary of
conclusions on treatment of, with
belladorma, 236^-9
Optic neuritis as indication of intra-
cerebral tumor, 454
Ossification of the ribs, 59-60
Osteomalacia, a case of, 26-7
Osteomyelitis, as characteristic lesion

of pyaemia, 186, 187, 190
Osteotomy, 81
Ovarian cyst, confusion of, with

renal, 15-17; 93-7
Ovariotomy, 5-7; cases of, 93-7; sep-
ticaemia in, 177; operation of, in-
itiated, 362

Pain, influence of, on the sphygmo-
graphic pulse-trace, 326-8

Palate, cleft, 411

Paralysis, facial and palatine, and
loss of equilibrium, caused by fall
upon the head, case of, 329-33;
of the new-born, 406

Paris, appointment of physicians to
hospitals in, i ; Academy of Med-
icine, I et passim; Imperial Soci-
ety of Surgeons, 1 1 ; International

Medical Congress at, 1867, 20-2,
34 flf. ; prostitution in, 47; ap-
pointment of hospital internes in,
81-2

Pasteur, attribution of putrefaction
to animal germs by, 173

Pellagria, 36

Pelvis, difficulties to childbirth in
abnormal narrowness of, 109-10

Pemphigus, 125-6

Pemphigus, herpetic chi;onic, 125

Percussion in pneumonia, 420-1

Petrous bone, lesion of, 330, 331

Phlebitis in pyaemia, 187 ff.

Phlegmon, oedematous, in gonorrhceal
rheumatism, 136

Physician, the, difficulties of his pro-
fession, 334 ff. ; sciences with which
acquaintance is necefesary, 337-8;
variety of knbwledge and capacity
for systematic mental combination
required, 338-9; specialists, 339-
40; mental culture, 340; capacity
for generalization, 340-1; train-
ing of the senses, 342; time re-
quired for training, 342 ff. ; com-
pleteness of knowledge demanded,
342-3; what a graduating medical
student should know, 343-5; co-
ordination of studies, 345-6; per-
sonal qualities needed, 346-7;
conditions under which a physi-
cian prescribes, 347-8; the three
primary capacities, 348; examin-
ing boards, 349; functions of col-
leges, 349; women medical stu-
dents, question of capacity, 349 ff. ;
difficulties in the way of women
students, 351-2; the remedy for
these difficulties, 352-3; the ques-
tion of marriage, 353 ; gynaecology,
353-5; difficulties connected with
medical schools for women, 355-6

Physiological experimentation on the
living subject, necessity of, 459-
60

Phthisis, see Tuberculosis

Pityriasis, acute, 124

Placenta, adhesion of, to uterine
wall, 312, 325

Placentitis, 324

Pneumatic occlusion, Guerin's sys-
tem of, lOI

Pneumogastric nerve, effect of sec-
tion or paralysis of, upon heart
action, 213

Pneumonia, catarrhal, 71-2; indi-
cation for quinine in (observa-
tions in 100 cases), 419 ff.; the
physical signs especially investi-

Index

519

Pneumonia — Continued
gated, 420; clinical analysis of
cases, 421-8; defervescence in,
428; explanation of fever in, 429;
vaso-motor system in, 429-30;
irritation of vagus in, 429-30; le-
sions and processes in, 430-2;
bacteria in, 431; theory of action
of quinine in, 432-3; size of doses
of quinine to be used in, and tis-
sues affected, 444; characteristic
indication for use of quinine in,

444

Polypus, naso-pharyngeal, operations
for, 62-4

Pons, probable tvmior of, a case of,
446 ff.; a similar case with autopsy,
452-3; reasons for the diagnosis,
455-6

Post-Graduate Medical School, New
York, lectiu-e on diseases of chil-
dren at (1883), 403-18

Potassitun, bromide of, effect of, on
intracranial pressure, 309-10

Pregnancy, uterine reversion during,
77-80

Prostitution, 46, 47

Priu-igo, 126

Psoas-iliac abscess, 87-8

Psoriasis, 126

Ptisans, 50

Pulmonary consumption, 3-4

Pulmonary emboli as a consequence
of congelation of the limbs, 76-7

Pulse, effect of atropine on, 206-14;
effect of morphine on, 225

Pulse- trace, sphygmographic, influ-
ence of pain upon, 326-8

Pus, in infective processes, 191 ff.

Pyjemia, pathogeny of, 171 ff. ;
definition of, 176; origin and course
of, 182 ff.; characteristic lesions of,
186 ff. ; inquiry as to causes for
differences from septicaemia, 195
ff. ; of new-born, 407

Q

Quinia, effect of, on intracranial
pressure, 303-5

Quinine, indication for, in pneu-
monia, 419 ff. ; clinical analysis of
100 cases of pneumonia in which
it was used, 421-8; theory of its
action, 432-3; action of, on heart,
433 ff. ; experiments with, on frogs,
434-8, 439-44; size of doses, 444;
characteristic indication for its
use in pneumonia, 444

R

Rachitis, 408, 414

Radius, fracture of, treatment of,
89-90

Reabsorption of retained urine, 90-1

Recttun, cancerous stricture of, diag-
nosis of, 91-2

Renal cyst, confusion of, with ova-
rian, 15-17

Renal infarctus of the new-born, 408

Retention of urine, 90-1

Rheiunatism, cases of complicated,
1 10-13; gonorrhoeal, 133-7; as-
sociation of chorea with, 137-43

Ribs, ossification of, 59-60

Richardson, J. G., experiments with
bacteria, 175

Roseola, 127

St. Anthony's fire, 126
Scrofula, 118-20, 127 ff.

Semi-circular canals of the internal
ear, lesion of, 330, 331, 332

Septicaemia, pathogeny of, 171 ff. ;
definition of, 176; occurrence of,
177 ff.; symptoms in, 179-80;
artificial, 180; variable degrees of
intensity, 180-1; gravity of, 181-2;
pus in, 191 ff. ; inquiry into causes
for differences from pyasmia, 195 ff.

Sims, invention of speculum by, 362

Skin diseases, classification and dis-
cussion of, 115 ff.; pathology, diag-
nosis, and treatment of, 124 ff.

Sleep, hypnotic, 488-90

Somatoscopy, apparatus for, 48-9

Specialism in medicine, 357 ff. ;
relation of specialist to general
practitioner, 357; what is expected
of the specialist, 357-8; complete
theory of practical specialism, 359;
special temptation of the specialist,
360; inconveniences of the tend-
ency to universal specialism, 360-
l; discussion of claims of advan-
tages of specialism, 361 ff. ; re-
Search work, 364-5

Speculum, invention of, by Sims, 362

Speech, location of power of, in
the brain, 3

Sphygmographic experiments on a
human brain, 299-310

Spinal cord, as real seat of infantile
paralysis, 242 ff. ; theory of spinal
congestion in infantile paralysis,
266 ff. ; spinal hemorrhage, 269-
74; motor cells and nerve atrophy,
274-80

520

Index

Spine, curvature of, 59-60

Steam, treatment of stridulous laryn-
gitis with, 10

Sternum, fissure of, 412

Strabismus, in probable tumor of
the pons, 448-9

Stricture of the recttmi, cancerous,
diagnosis of, 91-2

"Subliminal consciousness," 490

Submaxillary gland, effect of atro-
pine on, 221-2

Suggestive therapeutics, 483 ff. ;
organic memories of pain or dis-
ability, 483-4; specific action of
hypnotic suggestion, 484; limit
of efficacy of, 484-5; relation of
brain to, 485-7; successful action
of, 487; faith curists, 487; neuras-
thenia, 488; gradual acceptance of
suggestion during successive hyp-
notic sleeps, 488-90; "subliminal
consciousness," 490; cases where
suggestion is ineffectual, 491-2;
"auto-suggestion," 493

Sulphide of carbon as a local anaes-
thetic, 1 13-14

Suprarenal capsule, 29

Surgical operations, prevention of
accidents after, discussion of, in
International Medical Congress of
1867 at Paris, 42-5

Surgical wards, isolation of, from
contagious diseases, 45

Sycosis of the beard, 125, 127

Syphilis, administration of mercury
in, 11-14; discussion on, at In-
ternational Medical Congress of
1867 at Paris, 45-7; hereditary,
time of appearance of, 408

Syphilitic acne of the beard, 127

Syphilitic indurations, primitive,
phenomena presented by, 61-2

Tartar emetic, effect of, on intra-
cranial pressure, 308

Temperature of the body, relations
of cerebro-spinal nerve-centres to,
473-4; relations of other nerve-
centres to, 474-6

Tetanus, 217

Therapeutics, suggestive, 483 ff.

Thoracentesis, operation of, 85-6

Thymus gland, 29

Thyroid gland, 28, 30

Toad venom, action of, on heart, 433

Tongue and pharynx, tumors of, new
operation for, 80-1

Tracheotomy, discussion on, at Paris
Academy of Medicine, 9-10

Tubercle, inoculability of, 65 ff.

Tuberculosis, discussion on, in In-
ternational Medical Congress of
1867 in Paris, 38-42; discussion of
treatise of M. Villemin on, 64-73

Tumor of the pons, a case of prob-
able, 446 ff.

Tumors of the tongue and pharynx,
new operation for, 80-1

Typhoid fever, bleeding in, II

Typhus, abdominal, 466

U

Umbilical hemorrhage, 313, 317-
20, 406-7

Umbilical hernia, 412

United States Army Medical Mu-
seum, catalogue of, 92

Uraemia, 90, 91

Urea, 161, 162

Urethral fever, 466

Urinary passages, dangers of ero-
sions of, 90-1

Urine, albuminous, 143 ff., 161, 162,
163, 164, 166; blood in, 161, 162,
163, 164, 166; epithelium in, 161,
163, 166; oil globules in, 161, 162;
casts in, 161-2, 164, 165, 166; fat
globules in, 167, 168

Urine, retention of, 90-1; reabsorp-
tion of, 91

Urticaria, 124

Uterine cancroid, 85

Uterine reversion during pr^^iancy,
77-So

Utero-ovarian disease traceable to
imperfect development, 478

Uterus, cancer of, iodoform in treat-
ment of, 7-8

Vascular glands, function of, 28-31
Vaso-motor nerves, function of, 60
Venous thrombi, as characteristic

of pyaemia, 186, 189-91
Vesico-vaginal fistula, 14-15
Vibriones, 175, 176
Virchow, 26, 35, 54, 157
Visceral abscesses, as characteristic

lesion of pyaemia, 186, 192-3
Vulpian, M., 19, 55, 245

W

Water, bacteria in, 174
White kidney, 153

Index

521

Woman's Medical College of the
Now York Infirmary, address to
graduating class (1872), 201-3;
lecture at, on atropine (1873), 204-
39; inaugural address at opening,
of Oct. I, 1880, 334-56; address
at commencement, May 30, 1883,
391-402

Women in medicine, 367 ff. ; social
opinion as to fitness of the profes-
sion for women, 367-8; most seri-
ous obstacles not always the most
real ones, 369; causes of prejudices,
370 ff. ; desire for women physi-
cians in India, 374-5 n.; the school-
boy argument, 377; the natural
history argument, 377-8; absurd-
ity and uselessness of the discus-
sion, 379; Huxley on capacity of
women for medical work, 379;
intellectual work required of a
physician, 379; modern develop-
ments in medicine increase its ac-
cessibility to women, 379-80; capac-
ity of women for mental initiative,
381; mental powers required, well
within capacities of women, 381;
fallacy regarding lack of self-
reliance and steadiness of nerve,
381-2; maternity as a factor, 382-
3; marriage, 383, 384, 385; typ-
ical case of a girl medical student,
385; adaptability of medical work
to exigencies of domestic life,
385-6; number of women practi-

tioners, 387; the demands of jus-
tice, 387-8; rearrangement of do-
mestic work, under modern indus-
tries, 389; professional work a
form of personal service, and, as
such, suited to women, 390; mon-
opoly of education by men, 393-
4; opposition to women students
and practitioners of medicine in
England and America, 394-5;
the subject of hospital and univer-
sity appointments, 395-7; how
women may contribute to their
own advancement to equality with
men, 398-9; abatement of hostil-
ity to women physicians, 400;
necessity for united action by,
494 ff. ; see also Physician

Women's Medical Association, ad-
dress before, about 1900, 494-500;
suggestions for work of, 497-500

Wood, Horatio, researches on fever
by, 473. 476

Woorara, 265, 434

Wounds, use of carbolic acid for
dressing of, 17 1-3, 198, 199; in-
fection of, 176 flf. ; aromatics and
balsams in treatment of, 284

Writing, location of power of, in the
brain, 3

Zona, herpetic, 125

R 1 1 7.J3

lU

3
O

ui

Q

R117
J3

Jacobi , Mary (Putnam), Mrs. t 1842-1906.

Mary Putnam Jacobi, M. D., a
pathfinder in medicine, with selections
from her writings and a complete
bibliography; edited by the Women's
Medical Association of New York City.
New York, London, G. P. Putnam's Sons,
1925.

xxxii, 521 p. diagrs. 24 cm.

114732

MBNU

09 MAY 77

2366584 NEDDbp

25-6636

R 1 1 7.J3

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